Summary: Mrs D complained about the quality of care provided to her mother Mrs X. The care provider failed to provide adequate care to Mrs X. There were a lack of adequate assessments and care plans and a lack of referrals for specialist input. This impacted on Mrs X’s well-being and caused Mrs D distress. The care provider should make a payment to Mrs X and to Mrs D to acknowledge the injustice caused.

The complaint

1. Mrs D complains Maypole Nursing Home failed to provide adequate care to her mother Mrs X. In particular, it failed to carry out adequate assessments and care plans, failed to regularly get Mrs X out of bed and failed to follow up an Occupational Therapy visit. As a result, Mrs X’s health deteriorated, and she is no longer able to get out of bed and sit in a chair. This is restricting her ability to socialise and impacting on her quality of life. This has also caused Mrs D distress.

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The Ombudsman’s role and powers

2. 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 34H(3) and (4), as amended)
3. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended). I have exercised my discretion to consider what happened from when Mrs X entered the care home in October 2015. This is because Mrs D was not aware of the injustice caused until much later and the complaint investigation shows the evidence exists to enable me to reach a decision on the complaint.
4. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
5. If we are satisfied with a care provider’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

6. I have considered the information provided by Mrs D in writing and on the telephone. I have considered the care provider’s response to my enquiries and the relevant law and guidance.
7. I gave Mrs D and the care provider the opportunity to comment on a draft of this decision. I considered their comments in reaching my final decision.
8. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share a copy of the final decision with CQC.

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What I found

9. 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.
10. Regulation 9 requires care and treatment to be appropriate and person-centred based on an assessment of their needs and preferences.
11. Regulation 12 requires providers to assess the risks to people’s health and safety during any care or treatment. This includes working with others such as health professionals to ensure the health, safety and welfare of the service user.

What happened

12. Mrs X has dementia. She moved into Maypole Nursing Home in late 2015 following a hospital admission after a mild stroke which left her unable to move one arm and reduced movement in one leg.
13. When Mrs X first moved to the care home Mrs D says she was able to sit in a chair and, using a wheelchair, family members were able to take her outside or to the communal area. Mrs D says she requested Mrs X be taken into the dining room to eat as she is sociable and enjoys chatting. Mrs D says the care provider tried this on one occasion but as Mrs X got upset so it did not try again. Mrs D says, over time, the care provider stopped putting Mrs X into a chair and stopped taking her into the communal area to take part in activities or to socialise.
14. The care records show the care home carried out a pre-assessment in Autumn 2015. It noted Mrs X required nursing care. She had dementia and left sided weakness following a stroke. She had no sitting balance and required the support of two people for transfers and personal care. Mrs X had a six-month stroke review in February 2016 which noted no issues.
15. The care provider completed care plans which were regularly reviewed and updated. These show Mrs X received regular personal care and her skin integrity was carefully monitored. Her eating and drinking plan was reviewed and amended in line with Mrs X’s changing needs.
16. In relation to Mrs X’s mobility, the safety care plan noted in March 2016 that Mrs X was sometimes helped into her chair but needed constant supervision due to poor sitting balance. The ‘my day, my life, my portrait’ completed in late 2015 noted Mrs X ‘loves chatting and mixing in small groups’.
17. The lifestyle plan in summer 2016 noted Mrs X was mainly nursed in bed, as per her choice. She was often visited by family and enjoyed talking about them. She did not wish to attend group activities. It stated ‘staff to gently encourage to socialise if possible. She enjoys 1:1 sessions with activities team’. The care provider’s records show Mrs X was regularly hoisted into a chair in January and February 2017.
18. In March 2017, the records of professional visits show the Doctor recommended a referral to an Occupational Therapist for postural cushions. This was due to ‘muscle contracture of legs causing difficult positioning’. The records show an Occupational Therapist visited later that month ‘re possible aids for leg positioning’. The notes record ‘nil prescribed but he will talk to his colleagues’.
19. The care provider’s notes show Mrs X was hoisted into a chair twice in March 2017, once in April 2017 and once in January 2018.
20. The lifestyle plan of care, completed in late 2017 noted Mrs X ‘used to enjoy gardening however unfortunately due to poor sitting balance [Mrs X] is unable to get out of bed and therefore is unable to go out into the garden’. The ‘my day, my life, my portrait’ completed in summer 2017 noted Mrs X had no sitting balance and was ‘nursed in bed at the moment’.
21. Mrs D was unhappy with the quality of care provided and arranged for Mrs X to move to another care home in early 2019. When Mrs X left the care home Mrs D says her leg was so bent due to contractures Mrs X could not sit in a chair and has to remain in bed.
22. She complained to the care provider in May 2019 about the quality of care provided to Mrs X. The care provider responded in July 2019. They found:
• very little detail documented in the pre-admission assessment. It recorded Mrs X had poor sitting balance but included no guidance on moving or positioning equipment, or seating that would enable her to get out of bed. It said this was cited through later care plans as the reason why Mrs X remained in bed.
• there was no evidence of Mrs X being referred to or assessed by a qualified specialist (eg a physiotherapist or occupational therapist) after her discharge to the care home and no referral for a seating assessment to enable her to get out of bed even with poor sitting balance.
• there was no reference to Mrs X’s limited mobility or the developing contractures in her leg in any of the moving and handling risk assessments or care plans completed at the care home. So there was no guidance for staff on how to prevent or treat the condition or how to effectively support Mrs X with mobility or transfers.
• The GP had referred Mrs X to an occupational therapist (OT) who assessed her for posture cushions in 2017. The care provider noted the OT planned to consult colleagues but there were no further entries or references to this in the care record.
23. It accepted there was more the care provider could have done to support Mrs X to get up and out of bed and to prevent the development of leg contractures. The care provider apologised that the care plans did not guide staff ‘to provide your mother with effective care to prevent a deterioration in her physical condition during her stay at the care home’.
24. It found evidence Mrs X had taken part in activities or received one to one time. They found no evidence Mrs X was ever consulted about where she would like to dine (in her room or communally in the dining room). So she may have missed out on the opportunity to socialise. It apologised for this. The care provider said, as a result of its findings, it was focusing on improving the overall quality of care planning. It noted the care home was not a specialist dementia care home. It was able to support those with cognitive impairment providing they did not walk around or call out in distress.
25. Mrs D also complained that when she visited Mrs X, she was sometimes uncomfortable or needed changing and she was unable to find a staff member to help. The care provider explained it was rare for staff to be visible as they were usually with residents providing support. It noted its call bell system had limitations. It was intending to replace this with a more modern system which would show who had been waiting longest.
26. Mrs D was also concerned staff did not appear sufficiently trained in dementia care. The care provider responded that 85% of staff at the care home had dementia awareness training. Its target was for 95% compliance so it would ensure this was more of a focus for training in future.
27. Mrs D remained unhappy and the care provider considered the complaint at stage 2 of its complaints’ procedure.
28. The care provider responded in August 2019. It noted the pre-admission assessment did not have enough detail and the care plans did not guide staff to provide Mrs X with effective care to prevent a deterioration in her physical condition during her stay. It reiterated the apology provided at stage 1. It said it was implementing a process to ensure the care home manager reviewed all pre-admission assessment documentation in future. It noted at the time of her admission Mrs X’s dementia was not considered an issue. It said there was a new manager at the care home who understood the need for a strong management presence to oversee the day to day running and to act as a contact point. Mrs D remained unhappy and complained to the Ombudsman.

Findings

29. The care provider, in its complaint responses, accepted it was at fault. These faults included:
• lack of detail in the pre-admission assessment, care plans and risk assessments.
• no referral for a seating assessment.
• lack of specialist input and failure to follow up the OT assessment.
• no guidance for staff on how to prevent or treat the contractures.
• no evidence it consulted Mrs X about where she wanted to dine.
• lack of reference to the contractures in any documentation.
30. Mrs X’s care was not in line with regulations 9 and 12 of the 2014 Regulations.
31. In response to my enquiries to the care provider, I have considered the care home’s records. I am satisfied the care provider has properly investigated the complaint and identified the faults in the care provided.
32. These faults caused Mrs X an injustice. Mrs X had suffered a stroke and so was at risk of muscle contractures. However, the lack of personalised care and the failure to refer Mrs X to relevant professionals have, on balance, impacted on Mrs X’s well-being and Mrs X’s condition is likely to have deteriorated more than it would have done with proper care.
33. The first and only mention of Mrs X having contractures was the Doctor’s referral to an OT in March 2017. The care provider failed to follow up the subsequent OT visit. The records show that from this period onwards Mrs X was mainly nursed in bed. Mrs X also missed out on the opportunity to socialise with other residents, both through not being given a choice about where she liked to dine and due to the restriction in her mobility caused by the contractures. It is likely these faults have led to Mrs X experiencing increased social isolation. These faults have also caused distress to Mrs D.
34. The care provider has already apologised to Mrs D. The care home has also taken steps to improve its procedures, including:
• focusing on improving the overall quality of care-planning, ensuring plans are person-centred and are sufficiently detailed to effectively guide care, support and treatment;
• Implementing a process to ensure all pre-admission documentation is full reviewed by the home manager to ensure it is sufficiently detailed; and
• Increasing the amount of dementia awareness training at the care home.
35. In response to my enquiries the care home has confirmed it has:
• introduced a new call bell system which has reduced the call attendance times;
• increased staff training to 95% across the home; and
• is completing care plans within 24 hours of admission. These are reviewed by the manager and clinical team and audited 72 hours after admission to ensure the care plans are meeting the resident’s needs.
36. I am satisfied the care provider has taken action to prevent the recurrence of the faults identified in this complaint.

Recommended action

37. Within one month of the date of this final decision I recommend the care provider pays Mrs X an amount equivalent to 10% of the care costs paid between March 2017 when the contractures were first referenced to when she left the care home in January 2019, to acknowledge the impact the faults had on Mrs X’s well-being. It should also pay Mrs D £250 to acknowledge the distress this caused her.

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Final decision

38. I have completed my investigation. There was fault causing injustice for which I have recommended a remedy.

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Investigator's decision on behalf of the Ombudsman