Victoria Lodge (Select) Limited (19 005 885)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 10 Feb 2020

The Ombudsman's final decision:

Summary: Ms W complains Victoria Lodge failed to care properly for her father, resulting in two safeguarding enquiries which were upheld and her father having to move to another care home, and lost some of his possessions. There were failings by Victoria Lodge which left him without all the care he needed and could have put him at risk of harm. Victoria Lodge needs to apologise, confirm it has waived any outstanding fees and take action to improve its practices.

The complaint

  1. The complainant, whom I shall refer to as Ms W, complains Victoria Lodge failed to care properly for her father, resulting in two safeguarding enquiries which were upheld and her father having to move to another care home. It also lost some of his possessions.

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The Ombudsman’s role and powers

  1. We investigate complaints about adult social care providers. If there has been fault, we consider whether it has caused an injustice and, if it has, we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(4), as amended)

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How I considered this complaint

  1. I have:
    • considered the complaint and the documents provided by Ms W;
    • discussed the complaint with Ms W;
    • considered the comments and documents Victoria Lodge has provided in response to my enquiries;
    • considered Dudley Metropolitan Council’s (the Council) records about the safeguarding concerns; and
    • shared a draft of this statement with Ms W, the Council and Victoria Lodge, and taken account of the comments received.

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What I found

Key facts

  1. Ms W’s father, Mr X, has dementia. He went to live at Victoria Lodge in May 2017.


  1. When Ms W visited her father on 28 November 2017 she raised concerns about him becoming dehydrated; he could not open his eyes or speak. She gave him water to drink and he started to improve. The next day both Ms W and Victoria Lodge reported this to the Council as a safeguarding concern. Ms W said this had happened a couple of times but generally her father was well cared for. Victoria Lodge said it had assigned a member of staff to give hourly drinks and record this on fluid charts. The Council did not make formal enquires into the safeguarding concerns. This reflected the fact Victoria Lodge was already taking action to address the problem.
  2. Victoria Lodge says:
    • it received medical advice on 13 November to increase Mr X’s fluid intake;
    • it therefore started using a fluid balance chart;
    • after this Mr X’s medical presentation stabilised and improved;
    • on 28 November Mr X’s condition declined;
    • it sought medical advice and an Advance Nurse Practitioner visited;
    • Ms W arrived while the Advance Nurse Practitioner was there;
    • the medical assessment decided Mr X had a chest infection and a potential urinary tract infection, although the latter was not formally diagnosed;
    • the Advanced Nurse Practitioner prescribed antibiotics which he started taking that day;
    • the symptoms of an infection can include drowsiness, dehydration, confusion, decreased mobility, decreased appetite and decreased conscious levels;
    • antibiotics can take up to 72 hours to show an improvement, during which time symptom can continue.


  1. Victoria Lodge kept records of the care provided for Mr X. There are too many to list here. However, I refer to the key contents of the records from November 2018 until Mr X left Victoria Lodge. The records show Victoria Lodge reviewed most of Mr X’s care plans each month.
  2. Victoria Lodge recorded Mr X’s food and fluid intake. The records show staff regularly helped him with drinking. The charts say to give fluid every 2 hours. They identify variable targets for daily fluid intake: 2,000/2,025 ml; 2,325 ml; and 1,786 ml. The latter is from 8 March 2019. But his fluid intake was often below the target level. Mr X mostly ate all his meals without help. Victoria Lodge weighed him each week. In December 2018 his weight had dropped from 61.5 kg to 58.2 kg. His weight increased to 59.4 kg in January but dropped to 58.00 kg before he left in April. However, his MUST (Malnutrition Universal Screening Tool) score remained acceptable.
  3. Mr X could walk short distances with the help of two staff but needed a wheelchair for longer distances. Sometimes he needed hoisting because of pain in his knees. He wore incontinence pads, which staff were to check every two hours at night and “regularly” during the day. The daily care notes only record the night checks for the week before he left in April 2019.
  4. The daily care notes say Mr X would spend his days in the lounge listening to or watching the TV, sometimes sleeping, occasionally chatting to staff or other residents. One of his care plan evaluations says he liked to sing along when a singer came in every two weeks. He also had visits from family.
  5. The care plan evaluations for personal care say to offer Mr X a bath and apply creams after personal care. They say to shave him daily with an electric shaver. He needed one person to help with personal care but two for hoisting. The only references to personal care are in the daily care notes. There are only two references to offering Mr X a bath in the daily care notes Victoria Lodge has sent to me (on 22 January and on the day he left). There are five references to “personal care”, five references to washing and only one reference to washing Mr X’s hair. Ms W says her father was often unwashed when she visited, rarely had his hair washed, and often smelt of urine.
  6. On 9 November Mr X had “suspected shingles” and was kept in his room. After a GP’s visit he was allowed to go to the lounge in the afternoon of 10 November. Ms W objected to Mr X being left in his room for 36 hours with no stimulation.
  7. Victoria Lodge says:
    • Mr X had a rash on his back on 9 November so it phoned NHS 111 and was advised to contact a GP;
    • the GP advised isolating Mr X in his room and said a GP would visit;
    • it chased this up on 10 November and a GP visited later that day;
    • the GP said Mr X did not have shingles and prescribed a barrier cream to “aid and absorb moisture”;
    • in isolating Mr X it had followed medical advice.
  8. On 16-18 November Mr X remained in his room due to sickness and diarrhoea.
  9. When Ms W visited her father on 8 April 2019 his trousers were wet, having spilt his drink. He had been that way for over an hour. When Ms W pointed this out to staff they arranged for him to have a bath and put him in dry clothes. Both Ms W and Victoria Lodge reported the incident to the Council as a safeguarding concern. Ms W also mentioned the incident from November 2017. She said she wanted her father to leave Victoria Lodge as there were too many problems:
    • hair not cut or washed;
    • lack of mouth care;
    • nails uncut;
    • food on clothes;
    • urine stains on trousers;
    • left cold without a vest or cardigan;
    • telling Ms W to cry in front of staff so they would “learn”.
  10. On 10 April Victoria Lodge told the Council Mr X had been neglected on 8 April. It put this down to the action of a member of staff.
  11. With help from the Council, Ms W arranged for her father to move to another care home on 11 April. She told Victoria Lodge she would not pay for her father’s placement after March. Victoria Lodge initially charged Mr X £3,684.56 for 1-28 April. On 29 April it issued a credit note for £2,237.05 for 12-28 April, reducing the bill for April to £1,447.51. Victoria Lodge says it has waived the outstanding fees.
  12. On 11 April Victoria Lodge told the Council Mr X had advanced dementia and should have moved to the dementia care floor but Ms W would not agree to this.
  13. On 18 April Ms W e-mailed Victoria Lodge saying:
    • some of his CD’s were missing although they had been in his room two weeks ago;
    • his wedding ring was missing, which had been on a chain in a heart shaped box in his sideboard;
    • despite asking about her father’s left eye for several weeks, it turned out he needed treatment for conjunctivitis.
  14. Victoria Lodge sent its final response to Ms W’s complaint on 4 June, which includes these comments about the more recent events:
    • the Manager understood she had addressed Ms W’s concerns on 8 April;
    • she had been asked to put her complaint about the Manager in writing so a more senior manager could respond to it;
    • Victoria Lodge had no records to suggest Mr X had conjunctivitis. It noted his new care home had not identified the problem until after he had been there for three days.

Missing possessions

  1. When Mr X arrived at Victoria Lodge it completed a property checklist. This lists the clothing he brought with him and mentions 14 framed pictures which had been put on the wall. It does not mention any other personal possessions, including jewellery. The checklist is not signed by anyone.
  2. After Mr X left Victoria Lodge, Ms W reported a missing wedding ring and missing CDs. Victoria Lodge has provided a hand-written inventory which lists clothing and other items including: royal mail certificates; stereo; shaver (electric); “numerous picture frames”; and “numerous models of cars, buses”. On 18 April Victoria Lodge noted staff said the CDs were on Mr X’s dresser (but they did not recall how many there were) and they could not recall him wearing a wedding ring, just a silver ring with a black stone (as shown in a photograph). In early May Victoria Lodge took statements from staff, none of whom recalled seeing Mr X wearing a wedding ring, just the silver ring with a black stone.
  3. Victoria Lodge’s admissions policy, updated in November 2018, provides for an inventory to be signed by the “nominated person”. The Resident Agreement says personal effects can be taken into safekeeping, but the company does “not accept responsibility for missing items, monies or valuables”. It says insurance is provided up to a maximum value of £500 for the personal effects (excluding cash, jewellery) left in the resident’s room”. The Resident Agreement does not mention the inventory or the need to update it if additional items are brought in.

Did the care provider’s actions cause injustice?

  1. Victoria Lodge has explained the circumstances leading to Mr X becoming dehydrated in November 2017. This suggests the dehydration was a symptom of another illness rather than due to poor care.
  2. In November 2018 Victoria Lodge was following medical advice when it kept Mr X in his room. I cannot criticise it for that.
  3. There is no dispute over the fact Mr X was neglected on 8 April 2019. This did not cause significant harm to Mr X. However, Ms W was distressed at finding her father had been left in wet clothes.
  4. Victoria Lodge’s care records are incomplete:
    • although it kept detailed records of Mr X’s fluid intake it is unclear how it set the fluid target or what, if anything, it did about the fact he often did not drink as much as he needed to;
    • it had identified the need to check Mr X two-hourly at night but did not start recording these checks properly until a few days before he left in April 2019.
  5. These are faults which could have put Mr X at risk of harm.
  6. There is little evidence in Victoria Lodge’s records of providing Mr X with the help he needed with personal care. It can be helpful to keep specific records for this, rather than rely on the daily notes. The lack of evidence in Mr X’s records is fault. This supports Ms W’s claim that staff did not help Mr X with washing as often as they should have done. That is an injustice which warrants a financial remedy. However, Victoria Lodge says it has already waived all the fees for April 2019. I cannot ask it to do more than that, but it needs to confirm in writing to Ms W that it has waived the fees.
  7. The inventory from when Mr X arrived is not signed, so there is no evidence it was agreed with Mr X or his family. It seems likely Mr X was wearing the silver ring when he arrived, but this was not included. It was therefore incomplete. It appears his family brought more things in for him after he arrived (e.g. the stereo and the CDs) but the inventory was never updated, making it meaningless. If an inventory is made it needs to be kept up-to-date, otherwise there is no point in making one. The inventory made on his departure was clearly not referenced against the first inventory. It appears Mr X did not wear his wedding ring but kept it in a box. That staff did not see him wearing it is therefore not surprising. It is helpful for care homes to advise people not to bring valuables in with them, such as jewellery they do not wear, as it can be difficult to keep track of them, particularly when someone has dementia. It is not possible for me to say what happened to Mr X’s wedding ring and CDs. However, Victoria Lodge needs to improve its procedures for dealing with the possessions of residents.

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Recommended action

  1. I recommend Victoria Lodge within four weeks:
    • writes to Ms W apologising for the failings I have identified and confirms it has waived the outstanding fees;
    • reviews its procedures for dealing with personal possessions; and
    • produces an action plan, identifying the action it needs to take to make sure staff keep better records and deliver care in line with care plans.
  2. Under the terms of our Memorandum of Understanding and information sharing protocol with the Care Quality Commission, I will send it a copy of my final decision statement.

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Final decision

  1. I have completed my investigation on the basis that Victoria Lodge will take the action I have recommended.

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Investigator's decision on behalf of the Ombudsman

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