Summary: Mr X said the Burlington care home his father, Mr Y, stayed at for respite failed to care for him properly. He says Mr Y suffered injustice because of avoidable falls, isolation and weight loss. Mr X says he was personally affected because he was effectively ‘on call’ to help with Mr Y’s care and he does not consider he should have to pay the full invoice for poor care. We consider the home should have taken more care over Mr Y’s admission. Although it says it admits dementia residents, it is not a dementia unit and should have exercised caution at admission. However, it was not fully informed of Mr Y’s condition. To bring about resolution, I have recommended that the home reduce Mr Y’s invoice.

The complaint

1. Mr X says the care his father received during his respite stay was inadequate. He claims his father suffered:

• Avoidable falls,
• Isolation, and
• Weight loss.

2. He says his father was sometimes given the wrong medication or not given the medication prescribed.
3. He also claims he was regularly asked to help care for his father, including one incident where he says care staff sat around drinking tea while he had to lift his father from the floor.

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The Ombudsman’s role and powers

4. The Ombudsman investigates complaints about adult social care providers and decides 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)
5. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
6. 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.
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

8. Mr X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Pre-admission

9. Mr Y was 80 at the time his family arranged a respite stay for him at a Burlington care home, (“the Home”).
10. He was assessed prior to being admitted to the Home. Mr X says that a social worker and three members of his family were present at the assessment and the home’s manager, Mr D, was made aware of Mr Y’s condition.
11. The Home says the assessment was carried out over the phone and that the social worker explained to the family that Mr Y’s condition could decline when in a different environment.
12. The pre-admission care assessment, which appears to have been signed by Mr X, said that Mr Y suffered from dementia and other issues. The Home is not a dementia unit.
13. It was stated that Mr Y could be unsteady on his feet. He used a walking stick to steady himself. It was recorded that Mr Y “…can be a little agitated at times, no evidence of any challenging behaviours.”
14. In general, apart from it being noted that Mr Y suffered with dementia, the pre-admission care assessment did not indicate that Mr Y had any other serious requirements.
15. The Home says it transpired later (although Mr X says it was always known) that Mr Y had been known to Mental Health Services for some time. He had been diagnosed with Dementia with Lewy Bodies. This is a form of dementia which can cause, among other things, unsteadiness and falls, visual hallucinations and unpredictable periods of confusion.
16. Mr Y had also previously been prescribed a drug called Lorazepam, which is used for anxiety, panic attacks, for sedation and to treat insomnia. It can have the effect of increasing the risk of falls.

Following admission

17. Mr Y was admitted to the Home the next day. The Home says it prepared a contract. It says that although the family were asked several times, they refused to sign it. Mr X believes he did sign a contract.
18. The care records show that for the first week Mr Y seemed to get on well. The records indicate he ate well, chatted with staff, and attended a Christmas carol service.
19. But from 13 December 2019 onwards the records show he experienced confused periods.
20. On 15 December 2019, the care notes record staff talked with him, encouraging him to use his stick to walk with. But he was reported to show agitation with other residents.
21. There is some dispute about when the home was first made aware that Mr X took Lorazepam to calm his dementia. The Home says Mrs Y produced a strip from her pocket when the family attended Mr Y while undergoing an episode of challenging behaviour. Mr X says this is not correct and that he had brought Lorazepam to the Home. He said it had been prescribed over a year ago and had not been given to the Home along with his other medication at admission. He says this was because Mr Y only needed it occasionally.
22. There is also some dispute about who called a dementia specialising agency to the Home. The Home says Mr X called the agency from his phone and Mr X denies this.
23. The records I have seen do not record that Mr Y’s wife produced a strip of Lorazepam from her pocket. But it is recorded that a nursing agency attended when called. It does appear to have been at this point that the Home was informed Mr X had been prescribed Lorazepam.
24. The Home says it served notice on Mr Y on 16 December 2019 because it did not consider it was the appropriate care placement for a gentleman with his needs. This is odd as Mr X says he did not receive a copy of the notice and the medical professional who saw Mr Y on 19 December 2019, after speaking with the manager, said the Home was, only at that stage, “considering giving [Mr Y] notice due to the risks he pose[d] to others.”
25. By 18 December 2019, the Home received further medical advice and Mr Y was prescribed a regular dose of Lorazepam alongside a dose to be taken as and when needed. The medical professional who saw Mr Y noted that he had previously been prescribed Lorazepam but Mr D said the Home had not been informed.
26. The medical professional also recorded that she spoke to Mr X. She said she told him that in her opinion Mr Y needed a full health and social care needs assessment to find a placement that was appropriate for his needs. She said she offered to make a referral. However, she says Mr X said his mother would do that. By the time she wrote up her note about the assessment, on 20 December 2019, she said a referral had not been made. As Mr Y’s behaviour had continued to be challenging, she made an emergency referral to social services.
27. The care records show Mr Y continued to have episodes of challenging behaviour. The records show Mr X was called out to help calm Mr X. Mr X says this happened on more than ten occasions and he felt like he was ‘on call’.
28. The Home’s records state that if staff were unable to calm Mr Y or to give him his medication, “after trying all options” they should call Mr X, who Mr Y always responded well too.
29. On 28 December 2019, Mr Y had an unwitnessed fall. He is recorded as having a small injury to his wrist but nothing serious.
30. On 30 December 2019, the notes show the home was becoming increasingly concerned about Mr Y’s escalating behaviours. It recorded that it had called Mr X to the home on a number of occasions, but that Mr X’s family had said they were no longer willing to attend. Mr X says that he always attended when asked and is offended that the Home recorded he was unwilling to do so.
31. However, on 3 January 2020, the notes record the Home considered it had to call Mr X after an aggressive incident. The notes record that Mr Y pulled one of the staff to the ground. Another member called social services for help and was advised to call the police. It does not appear this was done as the staff member called Mr X instead. Mr X was able to settle Mr Y quickly.
32. A few days later Mr X had another unwitnessed fall while in his room. He was taken to Accident and Emergency. Mr X has provided photographs of Mr Y’s bruising. I am not a medical professional and can make no analysis of Mr Y’s bruising, other than that it appears, on the face of it, to be consistent with Mr Y’s falls. Mr X later said the hospital doctor was more concerned with his father’s blood count through bruising rather than the reason for attending hospital after a fall.
33. Shortly after being discharged by the hospital, Mr Y was transferred to another home.
34. Mr X complained about the care Mr Y had received at the Home and a number of other issues, including:
1. That his father was left alone in his room.
2. Lost 2kg in weight in two weeks – his food was simply left in his room.
3. Had his walking stick removed, which led to falls.
4. His bruising.
5. Missing items of property.
6. Not enough training given to staff.
35. Taking the list I have set out in para 33 in turn, this was the Home’s response, in summary:
1. Numerous records indicated Mr Y was in the main reception area, although he was directed to his room when being aggressive.

The records I have seen support this.

2. Mr Y sometimes refused food. But overall he had a good dietary intake. It is possible that his pacing around the home contributed to weight loss.

The records support this.

3. Mr Y’s walking stick was removed on five occasions. He had struck staff. He was assessed for a zimmer frame on 16 December. This was ordered but he refused to use it and his stick was returned to him.

The records support this.

4. Mr Y had three falls in four weeks. The home said that upon checking the records, it was not stated that he needed support when mobilizing.

(I note however that a risk assessment dated 6 December said there was moderate risk with mobility and function).

The Home says it does not consider three falls to be excessive. It says Mr Y’s bruising would have contributed to his low blood count. His aggressive physical outbursts, including punching walls, turning over furniture and ripping wardrobe doors off would have contributed to his bruising. The Home said discharge information from the hospital did not allude to any concerns about his blood results.

I note that the discharge sheet did appear to suggest (it is difficult to read the writing), that Mr Y’s GP was to repeat his blood tests in one week.

5. One missing item of property was returned. The home compensated Mr X for the loss of a jumper.
6. The home is not a dementia unit. It says staff did not have training to deal with the types of behaviour exhibited by Mr Y’s condition.
5. It added that Mr Y’s family had not informed the Home of Mr Y’s condition. It said that had it been made aware he was known to mental health services the Home would not have agreed to provide Mr Y with a placement.
6. With regards to Mr X having been called out on a number of occasions to assist with his father, the Home said:

“I am sorry if you think that by admitting a family member into a care home absolves you of all responsibility as this is not the case and unfortunately, sometimes staff have to resort to the next of kin to assist with daily care where they are not able to….your fathers care was a joint responsibility at that time and ongoing.”

38. Mr X was offended by the above statement and said the Home was fully aware of his father’s needs when he was admitted.

Analysis

39. The Home was misguided when it told Mr X that when a resident is admitted to a home, the relative still maintains responsibility. When a person enters a care home, under a contract of care, the home is, by the nature of the service it provides, taking on full responsibility for the care of that resident.
40. Even if Mr X had refused to sign a contract of care, when Mr X asked the Home to take care of Mr Y, and the Home agreed to do so, it was understood that the Home would take on full responsibility for Mr Y’s care. That was the service the family were paying for. Even though the records show staff were told to contact Mr X, after every other effort had been made, I have not seen any side-agreement indicating Mr X agreed to that arrangement.
41. Mr X says the Home was fully aware of Mr Y’s condition prior to admission. He says Mr Y’s social worker can confirm this. I have not interviewed Mr Y’s social worker. The passage of time is too long, and I have other evidence to assist. It is clear from the pre-admission care assessment that the Home knew Mr X suffered with dementia. Although I accept it was not aware he took Lorazepam, (which I will address below), it was aware he had been prescribed other medication to help ease the effects of moderate to severe cases of dementia. It is odd that the Home’s manager seemed surprised that a nursing agency that specialised in dementia was familiar with the family - his pre-admission care assessment stated he suffered from dementia.
42. Dementia can affect different people in different ways. Sometimes people do not present challenging behaviours. It may have been that the Home considered this could be the case with Mr Y. But, given that the Home is not a dementia unit and it says its staff do not have the training to care for dementia patients, it should have exercised more caution when admitting a patient who took medication for dementia. (The pre-care assessment did not mention that Mr Y was prescribed such medication but the Home was aware because it administered it from day one.)
43. The fact that Mr Y was on this medication should have alerted the Home to the risk that Mr Y might present challenging behaviour. But in any case, it knew his condition might decline. It says it advised Mr X about this at the point of admission. Therefore, even though it was aware there was a risk he could decline, and it was not a dementia unit, it still provided a place.
44. The Home says it was an emergency placement. It may have been that, to help Mr Y’s family out at a difficult time, it felt it was able to take a risk. But that is what it was. As it transpired, Mr Y presented very challenging behaviour and the Home did not have the systems or staff in place to care for him in the way he needed. This caused Mr Y an injustice. He was placed in respite care that was not suitable. It also caused Mr X an injustice because he was concerned about the care his father was receiving and was ‘on call’ to help staff who were unused to dealing with challenging behaviour.
45. But, while I consider the Home should have shown more professional curiosity prior to admission about Mr Y’s condition, it is also correct that Mr Y’s family could have provided the Home with more information about his history.
46. I accept, from the accounts in the records I have seen, that the Home was unaware of Mr Y’s full diagnosis. It was unaware he had been prescribed medication to calm him and relax his agitation. While I have not seen Mr Y’s medical records, it is unlikely he was prescribed that medication unless he had exhibited challenging behaviours in the past. It does not appear the Home was informed of this. Even if Mr Y had demonstrated these behaviours some time ago, it was still relevant information and his family were aware he had a prescription for Lorazepam. The Home says that if it had known, it would not have given Mr Y a place.
47. On balance, given that the Home admitted Mr Y knowing he had dementia and it was not a dementia unit, I consider it unlikely the extra knowledge that he was taking other medication, would have made enough of a difference for it to have refused Mr Y a place. I say this bearing in mind that he was only previously prescribed Lorazepam to take when required. This suggests that prior to admission the family were not aware of regular outbursts of aggression. Given that the Home clearly felt it could manage his dementia condition, it is likely that it would still have felt it could have managed Mr Y’s behaviour.
48. But because the family did not provide the Home with Mr Y’s full history, I am not overly critical of the Home’s repeated request for Mr Y to attend and help with care of Mr X. If the Home had been made aware from the start that Mr Y had a prescription for taking Lorazepam, it might have, a) been better prepared to respond to his behaviour and b) possibly been able to handle his behaviour with the aid of medication without having to repeatedly call on Mr Y. I cannot say for certain. But I have taken the family’s omission to provide information into account when making my recommendations.

Other parts of complaint

49. With regards to the other heads of complaint, I have found no evidence that Mr Y was given the wrong medication. The records show he was given his medication regularly. However, there were occasions when the records show he was not given his medication. The records show that a note was made that if Mr Y missed his medication on more than three occasions, a doctor should be called. The records show that staff sometimes found it difficult to administer his medication and called Mr Y to help. The fact that they endeavoured to do so, even though Mr X was unhappy about regular calls, indicates that every effort was made to ensure Mr Y had his medication.
50. The records also show that Mr Y was not isolated. The records show he regularly took his meals in the dining room and that he attended Christmas parties etc before his behaviour started to become more challenging.
51. The Home’s explanation for Mr Y’s weight loss seems reasonable. I have seen the menu offered to Mr Y. It was varied and it does appear that Mr Y more often than not, ate the meals offered. The records indicate care was taken about meeting Mr Y’s tastes, noting that he did not, for instance, like spicy foods. However, he did, on occasion refuse to eat and the home respected his decision when that was the case. Mr Y was seen regularly by a doctor and there is no mention of any concerns with his health related to diet.
52. Although Mr Y had a number of falls, sometimes this can not be helped. He was on medication that increased his risk of falls and he clearly experienced a number of periods where his confusion was heightened, which would have added to that risk. The records show staff acted appropriately when he had falls. While he suffered bruising, this appears to have been in line with his falls. I rely on the fact that Medical professionals at the hospital saw Mr Y after his falls. While I disagree with the Home that there was no concern about his blood count levels, there was no heightened concern, with the hospital doctor only asking for his levels to be checked the following week.
53. I can make no comment on Mr X’s allegation that staff sat around drinking tea while he lifted his father from the floor. The Home deny this happened and as I was not there, I am unable to reach a conclusion.

Conclusions

54. What I consider material to this investigation is that the Home was aware Mr Y suffered from dementia when he was admitted. Since writing my draft decision the Home has said that its staff did have dementia training. However, it informed Mr X in complaint correspondence that it was not a dementia unit. It was unprepared to care for Mr Y when his behaviour escalated, and it had anticipated this could happen. This is fault. It caused Mr Y and Mr X an injustice as noted above.
55. But it is also notable that Mr Y’s family were aware he had been prescribed other medication for dementia that the Home was not informed about. I do not consider, given that the Home took Mr Y in, knowing he had dementia anyway, that this would necessarily have stopped Mr Y being admitted. But, it may have helped the Home anticipate Mr Y’s behaviour, respond to it with more confidence and reduce the need for the number of call-outs. Therefore, while I have made a recommendation that Mr X or his family should not have to pay Mr Y’s full fees, I have borne this in mind.
56. I have also borne in mind that the Home appears to have provided a good standard of care to Mr Y. I have not found evidence that it did not take good care of Mr Y and only seemed unable to care effectively for him when he was experiencing the more severe symptoms associated with his condition.

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Recommendations

57. Within a month of my final decision, the Home should:

• Re-issue the invoice for Mr Y’s care. It should reduce the sum sought by a quarter to reflect the fact that as a residential and not dementia unit, it was not always able to respond effectively to Mr Y’s occasionally challenging behaviours.

58. Within two months of my final decision, the Home should:

• Reflect on how Mr Y was admitted, given that it was aware he was a dementia patient. It should consider improving its admissions process to ensure it only admits residents it is able to care for fully.

59. The Home should provide evidence to the Ombudsman that it has completed the above.

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Final decision

60. I have found the Home at fault and made recommendations to remedy that injustice. I have now completed my investigation.

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Investigator's decision on behalf of the Ombudsman