Summary: The care and treatment provided to Mrs X did not always meet expected standards. The actions of the care provider caused injustice to Mrs X, which it agrees to recognise by a payment for her benefit.

The complaint

1. Mrs A and Mrs T (as I shall call the complainants) complain about the care and treatment of their elderly mother Mrs X in the care home. In particular they say her call bell was removed, the food was not suitably prepared for her, she often complained of feeling cold, and medication was not given covertly as agreed.

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What I have investigated

2. I have investigated the complaint as set out above. I explain at the end of the statement why I did not investigate other matters.

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The Ombudsman’s role and powers

3. 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)
4. 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

5. We spoke to Mrs A and Mrs T. I considered the information provided by Mrs A, Mrs T and the care provider. Both parties had an opportunity to comment on an earlier draft of this statement and I considered their comments before I reached a final decision.
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Relevant law and guidance

7. 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.
8. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
9. Regulation 10 says service-users must be treated with dignity and respect at all times.
10. Regulation 11 says care and treatment must only be provided with the consent of the service users.
11. Regulation 12 says arrangements for giving medicines covertly must be done in line with the Mental Capacity Act.
12. Regulation 14 (meeting nutritional and hydration needs) says providers should have a food and drink strategy that addresses the nutritional needs of people using the service. It says “A variety of nutritious, appetising food should be available to meet people’s needs and be served at an appropriate temperature.” It also says, “Where a person is assessed as needing a specific diet, this must be provided in line with that assessment”.

What happened

13. Mrs X moved into the care home in September 2018. She is partially blind, has dementia and is incontinent, although her daughters say she can ask to be taken to the toilet.
14. She was assessed at high risk of falling and had bedrails and bumpers in place. In her safety risk assessment it was noted she had previously had suicidal ideation and her wired call bell had been removed ‘due to suicidal attempts’ in February 2019. Mrs A and Mrs T say Mrs X did not have the strength to attempt to strangle herself. A wireless call bell pad was put in its place but staff noted she was unable to understand how to use it and just called out instead (although her daughters say the batteries were often missing). Her care plan said she should be checked hourly.
15. Mrs X’s care plan noted she needed a soft diet with food cut up into small pieces. She was able to eat and drink independently but the care plan identified she needed the support of staff to sit her up during mealtimes. A food and fluid chart was completed for her. Her care plan noted there were times she would eat well and ask for more; on other occasions she ate less. Her weight was described as ‘stable’. Mrs A says the food deteriorated while Mrs X was in the home and was certainly never a soft diet.
16. Her continence care plan noted she was usually aware when she needed the toilet and required assistance. However, the care home says usually her personal care needs were attended to in bed. The care home daily records note occasions on which she would remove her own pad and throw it on the floor. Mrs A and Mrs T say they purchased pants for her to ear instead when they discovered this but later found them unused in a wardrobe
17. The daily care notes also record frequent occasions when Mrs X removed all her bed clothes and then complained of feeling cold.
18. Mrs X took regular medication. In a medication review by the GP in June 2019 the care home notes record Mrs X had capacity to agree to her medication being crushed (or a liquid version administered) due to her swallowing difficulties but recorded ‘no need to be covert because patient is consenting’. Mrs A (who has power of attorney for her mother) says she personally signed the consent form for medication to be given covertly.
19. Her daughters say the standard of care deteriorated over the course of the year. They say they complained numerous times about the standard of food, the temperature in their mother’s room and the lack of available blankets, the smell or urine, and that she was told to use her incontinence pad when she asked for the toilet. They have provided emails showing the concerns they raised.

The complaint

20. In August 2019 Mrs A raised her concerns again during a visit to the home. She said her mother’s food was unsuitable (too hard and not cut up small enough). She also expressed concern that her mother was refusing her medication but the care staff were not following the GP’s instruction to give the medication covertly.
21. The deputy manager responded the next day. She said she had gone straight to Mrs X’s room after Mrs A had spoken to her and she agreed the food was too hard and not cut up into small pieces as it should have been. She added that Mrs X was evidently not coping with lumps in her food at all. She said she would ensure Mrs X was provided with a ‘soft’ diet and see if the texture and consistency suited her better.
22. The deputy manager also said the GP had stopped short of saying medicine should be given covertly but when she had explained to Mrs X the tablets could be crushed, Mrs X had then taken them with a spoonful of food.
23. Mrs A wrote again. She raised other concerns about the temperature of the food and added that if Mrs X could be persuaded to wear her bottom denture she might find it easier to eat. She asked why her mother’s tablets could not simply be crushed and given in a spoonful of honey to avoid her refusing them. She said the whole family was concerned that other residents sometimes wandered into Mrs X’s room. She complained Mrs X was cold and had told Mrs A she had been calling for help but no-one had come. She said the room smelled strongly of urine and Mrs X shouldn’t be told to use her pad when she said she needed the toilet.
24. The care home manager investigated Mrs A’s concerns and responded on 6 September. He agreed Mrs X ate better with her bottom denture in place but said while staff encouraged her to wear it, they could not force her to do so. He said the deputy manager and unit manager had spent some time with Mrs X observing the way she ate and considered she found a soft diet easier to swallow. He acknowledged the plate and food had been cold on the day Mrs A visited and said they were looking at other ways of maintaining the temperature of hot food.
25. The manager noted the family support for administering medicine covertly and said they had the support of the pharmacist to do so safely.
26. The manager said staff had placed a strap across the doorway to Mrs X’s room to deter other residents from wandering in uninvited. Mrs A says this only happened after she complained.
27. In respect of the temperature in Mrs X’s room, the manager said staff did their best to ensure Mrs X was comfortable. He said it was known that Mrs X would throw off her bedclothes saying she was too hot, then complain of the cold. He said the psychologist had formulated a care plan to support Mrs X with this.
28. The manager said when Mrs X told staff she needed the toilet, they would assist her by using the hoist. He added that as she was doubly incontinent sometimes her pad was soiled. He said all members of staff assured him Mrs X was not told to use her pad instead. He added that her room was cleaned daily and all efforts made to ensure it did not smell of urine, but Mrs X often removed wet pads and threw them on the floor.
29. The manager also referred to the report earlier in the year of a large bruise on Mrs X’s arm. He said they could not find evidence of a specific incident which had caused the bruising but noted it occurred at a time when Mrs X was unsettled, and would hit the bedrails. He also referred to the medications taken by Mrs X which had side effects of increased bruising. He apologized for the delay in responding to their concerns, which had been voiced several months previously.
30. In conclusion the manager said he was sorry Mrs A and Mrs T felt the standard of care and catering had deteriorated at the home.
31. Mrs A says despite the reassurances, they decided to move their mother from the home. In addition to their concerns about Mrs X, they also discovered three members of staff were arrested (although there was no suggestion Mrs X had been ill-treated). She says Mrs X’s mobility and social interaction has improved since the move.
32. A new manager has been in post at the care home since September 2019. The new manager says he checks the food regularly and the vegetables are soft to the point of being overcooked. He says Mrs X was able to express her views and would say if she did not like the food. He added however that the weight charts for Mrs X had not been reliably completed. He said if any weight loss was reported now, he would ensure the resident was weighed again to get reliable data and act accordingly.
33. The care provider says the removal of the wired call bell was agreed in a best interests decision meeting, which Mrs A attended. The wired bell was replaced with a wireless bell to remove the risk of strangulation (which Mrs A and Mrs T dispute).
34. The care provider says the temperature of the whole home was regulated by radiators but it was well-documented that Mrs X would complain of the heat, and throw the bedclothes off, then complain of the cold. Mrs A acknowledges this was her mother’s habit but says they could often only find thin blankets to re-cover her.
35. The care provider’s records (care plans and daily notes) provide evidence for the statements made by the care provider in respect of the removal of wet incontinence pads, the way Mrs X threw off bedclothes and complained of hot and cold, and the risk posed by the wired call bell. The records note the use of the wireless call bell pad was explained to Mrs X often but she did not understand its use and would call out instead.

Analysis

36. There were times when the care provider was slow to respond to the concerns expressed by Mrs A and Mrs T. That caused some injustice to Mrs X – she was presented with food which was not palatable (or hot), the records of her weight were variable, there was confusion about the removal of her call bell and whether medicine should be crushed or administrated covertly. In addition the care provider said it would respond quickly to the query about the bruise son Mrs X’s arm, but took several months and some prompting to do so.
37. The care provider has responded to the complaints but acknowledges there were faults. The care provider has also noted improvements in action since Mrs X moved.

Agreed action

38. Within one month of my final decision the care provider should apologise formally to Mrs A and Mrs T for the shortcomings which have been identified.
39. Within one month of my final decision, the care provider should offer £500 for the benefit of Mrs X in recognition of the times she received care which fell below the expected standard.

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Final decision

40. The actions of the care provider caused injustice to Mrs X.

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Parts of the complaint that I did not investigate

41. We explained to Mrs A and Mrs T that concerns about staffing levels and cleanliness should properly be raised with the CQC as the regulatory body.

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Investigator's decision on behalf of the Ombudsman