Belong Limited (19 002 568)

Category : Adult care services > Residential care

Decision : Not upheld

Decision date : 04 Dec 2019

The Ombudsman's final decision:

Summary: There is no evidence that the actions of the care provider caused injustice to the late Mr X. There were some disagreements about food quality and timing which the care provider sought to resolve. The care provider appropriately reported a near-miss incident with medication. The care provider sought medical attention promptly for Mr X.

The complaint

  1. Mr A (as I shall call the complainant) complains about the care and treatment of his late father Mr X in the Belong Morris Feinmann (BMF) care home. In particular he complains:
  • Food quality was poor and the important timing of his father’s meals was not followed;
  • A carer offered his father the wrong dose of medication;
  • Carers did not always attend his father promptly, and his call bell was moved one night;
  • Carers did not manage his skin integrity well;
  • There was a delay in obtaining medication and calling emergency services to take his father to hospital;
  • The care provider did not involve Mr A or Mrs X in formulating a ‘life plan’ for Mr X.

Back to top

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)

Back to top

How I considered this complaint

  1. I considered all the information provided to me by Mr A and by the care provider. I spoke to Mr A and to the care provider. Both parties had an opportunity to comment on an earlier draft of this statement and I took their comments into account before I reached a final decision.

Back to top

What I found

Relevant law and guidance

  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 - the statutory regulator of care services) has issued guidance on how to meet the fundamental standards below which care must never fall.
  2. Regulation 14 says that the nutrition and hydration needs of the service user must be met. This is defined (amongst others) as meeting the reasonable requirements of a service user for food and hydration arising from their preferences or their religious or cultural background.
  3. Regulation 12 says that care and treatment must be provided in a safe way. This includes the proper and safe management of medicines. Regulation 12 also says that when responsibility for care is shared or transferred to other services, timely care planning should take place.
  4. Regulation 16 says that all complaints must be investigated and necessary and proportionate action taken in response to any failure identified.
  5. 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)

What happened

  1. Mr X moved into the BMF home at the end of February 2019 from his own home where his wife and son had cared for him for some time. He was 89 years old. He had capacity to make his own decisions about his care and treatment.
  2. The BMF manager says prior to admission, the care staff undertook an assessment at which Mr A and Mrs X were also present. The records show the care provider created an online care plan on 24 February, a few days prior to admission. The care plan refers to wishes apparently expressed by Mr A and Mrs X - for example “(Mr X’s) family will also like to be informed of any activities/trips that are taking place”; “(Mr X) will receive support from his wife and son in relation to support him with his financial management in order to act in his best interest.”
  3. Mr A says he and Mrs X were not involved in discussions about his father’s care while he was resident in the home. He says although they discussed how Mr X had been cared for at home, the life plan which the care provider formulated as a result of those discussions was not shared with them.

Complaints about timing and quality of food

  1. Mr X was admitted to the home on 26 February. The care plan says, “(Mr X) needs to have a diabetic diet and his meals at regular intervals. He also likes to have his medications with his meals. Therefore, (Mr X) needs to be woken in a morning between 7am-8.30am to have his breakfast; have his lunch about 12.30hrs and his tea at around 17.00hrs”.
  2. Care home records show that Mr A and Mrs X met the manager on 28 February to discuss their concerns that Mr X was having breakfast late, that he was being offered too many eggs, and there was too long a gap between his evening meal and breakfast. The care home notes record, “They claimed that he had rung his nurse call at approx. 07.50hrs, but it was half an hour before someone was able to assist him to get up.” The care note for 27 February is timed at 07.55 and reads ”Checked (Mr X) shouted Hello I went into see him and he asked for breakfast. was awake, was content.” The breakfast was served at 07.58. Mr A says this was recorded on an undated note and may have been written afterwards. The manager also added a list of Mr X’s food preferences to the care plan, at Mr A’s request.
  3. The online care planning and recording system used by the care provider records the time at which a carer makes an entry onto the system, rather than the time of the action. The times recorded for Mr X’s breakfast range from 07.58 to 11.23. Most of the records show that Mr X chose “a balanced diet”, ate most or all of his food and was “content”. Mr A says that either he or his mother visited Mr X every lunchtime and witnessed food being left.
  4. On 6 March and 15 March, Mr A and Mrs X met care home managers again to discuss their concerns about the food quality. Mr A said the soup offered was too spicy, the sandwiches were poor, the choice of dessert (a sweet potato cake) was not to everyone’s taste. The manager asked about the diet Mr X had eaten at home. She arranged for Mr A to meet the home’s chef, in the presence of Mr X, to discuss the food choices further. Mr A was given the opportunity to go through all the menu items and alternatives.
  5. On 16 March Mrs X went to the home with frozen fish fingers and a tin of baked beans and told staff Mr X was to have that for his dinner as he did not like the food being served. The carer on duty explained she had spoken to Mr A that morning as he said Mr X was finding it difficult to swallow and he did not want him to eat fish at the moment. The care notes record Mrs X said she was in charge of Mr X’s food and fish was difficult to swallow because of the way the staff prepared it. The care notes show that staff served the food which Mrs X had brought: Mr X ‘ate a little’.
  6. The records for the period of Mr X’s stay in the home show that he ate all or most of every meal he chose from the menu.

Medication incident

  1. On the morning of 1 March, Mr A telephoned the care home to complain that despite the care plan, Mr X had not yet been given his breakfast and medication. The care home manager went to investigate what had happened. Her incident report records, “I found that planned care, that I had put on the system the previous day to assist the gentleman to get up, have his breakfast and medications, had not been performed…. the Senior Support Worker was in the process of administering his medications, which he questioned, I double checked them and the wrong dosage of the medications had been put out. This was rectified and the correct dosage given to (Mr X). No evident harm came to (Mr X), as a result of these actions, however, the potential for harm was there.” Mr A says the care home manager was not on duty at the time and actually only became aware of the incident when Mr A telephoned her later.
  2. The care home manager suspended the senior support worker, pending investigation about both absence of planned care and a medication near-miss. Following investigation and then a formal disciplinary hearing the senior support worker was given a written warning and demoted.
  3. The care home manager also completed the statutory notification of the incident to the CQC and raised a safeguarding alert.

Failure to attend to Mr X promptly

  1. Mr A raised concerns about carers’ failure to attend Mr X promptly during the night on 16 March and said the call bell was out of reach.
  2. Mr A said his father had concerns about the attitude of the staff who attended him that night. Mr X said they “did not say much and did not smile”. He added, “I may be doing them an injustice but I’m sure they did not reattach my buzzer to me bed so I could not bother them”.
  3. The manager responded “The night documentation records that (Mr X) was checked at 02:02, 02:55 and was offered a drink, 04:00 he was assisted to the toilet, given a drink and supported to go back into bed…..One staff member confirms that the ‘buzzer’ had fallen off once during the night from the mattress onto the floor. It was offered to be clipped on the bed clothes but (Mr X) wanted it at the side of him on the mattress where he knew where it was. There is also a report that he was struggling to swallow and they spent 25 minutes with him to help him to drink. There is evidence from the nurse call report that (Mr X) had used his call bell on five occasions between 12.00am and 7.00am. On each occasion staff attended within 10 minutes.”
  4. The manager recorded the concern and notified the council’s safeguarding team on 18 March. Mr A has raised his concerns that the incorrect room was written on the safeguarding report.

Skin integrity

  1. The care provider’s records show that on 1 March a carer noticed an area of redness and contacted the District Nurses for assistance.
  2. The records for later that day note, “Seen nurse dn came to see potential moisture lesion on bottom and blister on foot but he would not let her see or treat these issues as he says his wife is dealing with them. The nurse tried to advise that savlon will only make the issue worse and barrier cream is more suitable. He still wants his wife to treat the blister and lesion so the dn is still going to get him some barrier cream just in case and i will get him a pressure cushion’.
  3. On 3 March the District Nurse attended again but Mr X still refused to let anyone but Mrs X treat the blister on his foot or the lesion on his buttock.
  4. Care notes confirm that the care staff checked skin integrity on a twice-daily basis as stipulated by Mr X’s care plan (‘The team will ensure (Mr X’s) pressure areas are healthy and intact twice daily during assistance with personal care’).

Alleged delay in obtaining medication and summoning emergency services

  1. On 14 March the care provider contacted the GP as Mr X appeared unwell. The GP prescribed medication for a chest infection.
  2. Mr A says there was a delay in obtaining antibiotics for his father’s chest infection because the care provider sources all its medication from a particular pharmacy. He says for that reason there was four days’ delay (from 14 March when the drugs were prescribed to 18 March) before the antibiotics were administered. He points out the care plan notes dated 18 March say antibiotics were given for 5 days. The MAR chart shows however that the first dose was given at 8pm on 14 March and the doses were all given until the last dose on 21 March.
  3. On 21 March Mr X’s condition was reviewed by medical staff and the care notes record, ‘Reviewed and no concerns expressed’. Mr A says this contradicts the outcome of his father’s nutritional assessment two days previously when he was deemed to be ‘at risk’ because of his low bodyweight and difficulty swallowing. The nutritional risk assessment has 5 levels: “a score of less than 8 indicates 'No risk'; from 8 to 11 indicates 'Cause for concern'; 12 to 14 indicates 'At Risk'; 15 to 17 indicates 'High Risk'; above 17 indicates 'Very High Risk'.” Mr X scored 14 on the assessment. The records show the care provider acted appropriately by ensuring “soft, bite-sized” foods were offered and by referring to the Speech and Language Therapy service.
  4. The care staff checked on Mr X frequently during the night of 21 March. On the morning of 22 March, the carer who brought breakfast at 08.32 noticed that Mr X’s breathing was shallow, although he said he was not in pain. She called the nurse to review him as he did not look well.
  5. The care staff called the GP at 09.04 as Mr X sounded ‘very chesty’. The GP returned the call at 10.59: ‘Doctor called. (Mr X) has been put on the doctors list for a visit. Dr will visit between 12-2pm.’
  6. The care records say the GP called to see Mr X at 1.00 and suggested an ambulance should be called. The care provider did so. Mr A escorted his father to hospital. A carer told the manager that when the ambulance team arrived, Mr A told them that his father's health deteriorated ever since he started living in BMF and ‘there was a medication error on the 1/03/2019 which he ostensibly thinks is more likely to have caused his father’s recent poor health’. Mr A says this is not true.
  7. Sadly, Mr X died in hospital on 24 March.

The complaint

  1. Mr A raised concerns about the care and treatment of his father. He wrote to the care provider with a formal letter of complaint on 12 April, having discussed his concerns with the management staff at BMF.
  2. The Chief Executive of Belong responded to Mr X. She apologised for the medication near-miss incident and confirmed it was reported to the council’s safeguarding team. She said apart from three occasions in the first week when breakfast was recorded as having been served later than planned, all care interventions had been delivered as planned. She reviewed the records for some occasions when Mr A said his father had been rushed or not had care delivered properly. She pointed out that Mr X had capacity to make his own decisions about whether to receive care. She said there was nothing in Mr X’s records to suggest the ambulance should have been called sooner on 22 March: it had been called as requested by the GP.
  3. Mr A complained to the Ombudsman. He complained the care provider had said he and Mrs X were involved in care planning when they were not. He complained about the food quality. He complained that staff had written the wrong location on a safeguarding report and he suggested this was done to cover up another incident which may have taken place.
  4. The Chief Executive says there were two separate investigations into the episode when breakfast was served late and the incorrect medication was about to be given. She confirms that a report was made to the council’s safeguarding team which investigated and took no further action. She says a credit note was issued to compensate for a three-day period on this first week of care when breakfasts were served late. She says a further credit note was issued for the three days Mr X was in hospital.
  5. The Chief Executive also says Mr X had capacity to make his own decisions about care and the choice of food he ate. She says he ‘was able to choose for himself what meals he preferred and did so despite how his son and wife felt about the food on offer’.


  1. The evidence from the care records suggests Mr X ate most or all of the food he chose from the menus. Although Mr A and Mrs X complained about the quality of food, there is no evidence Mr X did not or could not eat it.
  2. The care provider took appropriate action following the medication near-miss. No injustice was caused to Mr X.
  3. The evidence is that carers attended Mr X regularly during the night as planned and as required. Mr X expressed a preference for the call buzzer to be left next to him on the bed.
  4. The care provider sought nursing assistance promptly when Mr X’s skin integrity appeared compromised.
  5. The care provider sought medical attention promptly when Mr X was unwell and acted on the advice of the GP in calling an ambulance. The dates on the care plan (which record the day the notes were written rather than the actions taken) are confusing but the MAR chart is clear that the antibiotics were given from 14 March as prescribed.
  6. The pre-admission assessment was used to inform the care plan. There is no reason why the care provider should say Mr A and Mrs X were involved in the care planning if they were not, although I understand Mr A’s concern is that they should have been involved in and consulted about the care plan once Mr X was resident. There were regular discussions between the care provider and Mr A and Mrs X about Mr X’s care however.
  7. There is no evidence the care provider tried to cover up another incident by writing the incorrect location on a safeguarding report. The location had no bearing on the content of the report.
  8. The care provider ensured that Mr X’s nutrition and hydration needs were met. The care provider ensured safe care and treatment and recorded one near-miss appropriately. The care provider investigated Mr A’s complaints promptly and thoroughly.

Back to top

Final decision

  1. The actions of the care provider did not cause injustice to Mr X.

Back to top

Investigator's decision on behalf of the Ombudsman

Print this page