Summary: Mrs B complained about the care provided to her late husband at Sunrise of Hale Barns care home. She also complained about the charges which she says increased from the figure she was first given. She considered the poor care hastened Mr B’s decline and death. There was some fault which caused injustice to Mr B and Mrs B for which the care provider will apologise.

The complaint

1. I will call the complainant Mrs B. She complained about the care provided to her late husband at Sunrise of Hale Barns care home. She also complained about the charges which she said increased from the figure she was first given. She considered the poor care hastened Mr B’s decline and death.

Back to top

The Ombudsman’s role and powers

2. 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)
3. If an adult social Care Provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. We normally name care homes in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home. (Local Government Act 1974, section 34H(8), as amended)
5. We normally expect someone to complain to the Care Quality Commission about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended)
6. 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)

Back to top

How I considered this complaint

7. I considered the complaint and documents provided by Mrs B and spoke to her. I asked the Care Provider to comment on the complaint and provide information. I sent a draft of this statement to Mrs B and the Care Provider and considered their comments.

Back to top

What I found

Summary of events

8. Mrs B’s late husband had dementia. She needed some respite from caring for him so arranged for him to stay at Sunrise at Hale Barns, the Home. Sunrise Senior Living Limited run the Home. The Home suggested Mrs B should sign a contract for a permanent stay as that would be more economical than a respite placement.
9. In the middle of April 2019 Mr B moved in to the Home. Mrs B said she had some concerns about the care and there was a meeting with staff at the home a couple of weeks after Mr B moved in. The notes of the meeting from the Care Provider record that Mrs B was happy with the care.
10. In late June Mr B fell. The care home staff assessed him and decided he was not injured but the next day it was clear Mr B was in a lot of pain and an ambulance was called. Mr B was admitted to hospital. He had severe bruising and remained in hospital for six weeks. He then moved to a nursing home. He died a month later.
11. Mrs B complained to the Care Provider. She was not satisfied with the response she received so complained to us.

Analysis

Charging

12. Mrs B felt she had been misled about the fees that would be incurred. When Mrs B first contacted the home about a respite placement she was told those fees. But the contract Mrs B signed, before Mr B moved in, were clear that the fees were higher. So it was clear the terms on which Mrs B was entering into when Mr B moved in.

Care provided

13. The key issues here were Mr B falling and his nutrition.
14. Mr B weighed just over 62kg when he moved into the Home. When his weight was checked after he had been in the Home a month he had lost 2.5kg. The Care Provider has said he was still in the healthy range in terms of his BMI so there were no changes to the care plan and it was not discussed with the family. In responding to my further questions on this point the Care Provider said Mr B’s weight was not a major concern but would still need to be monitored closely for appropriate intervention as needed. The next intervention was a month later when he was weighed again. He had lost a further 3.6kg. The Home then contacted the GP and ordered fortified smoothies for Mr B. A food diary was kept for three days.
15. The Care Provider did not demonstrate it took adequate action in response to Mr B’s weight loss. At the first review he had lost 2.5kg which took him to the low end of a normal BMI (Body Mass Index) but there was not then a further check for a month. The Care Provider seemed to accept there should have been closer monitoring. After a further month Mr B had lost more weight taking his total weight loss to 6.5kg which was over 10% of his initial body weight. That did prompt some action but it was not adequately followed through. The care record showed Mr B having a fortified smoothie only once in the coming days and the food diary was incomplete on one day. There was no review after the three days. The Home did not, therefore, take adequate action in response to Mr B’s weight loss.
16. It is not possible to say whether this made any difference to the outcomes for Mr B. It may be that even with a more robust intervention Mr B would still have lost weight. But the Care Provider will apologise to Mrs B for the failings .

The falls

17. Mrs B was concerned Mr B was able to wander about the Home because he was sometimes unsteady on his feet so would fall.
18. Mr B had six falls in the first month he was in the Home. The GP visited at the end of May, reviewed Mr B’s medication but made no other interventions. There was a further fall in early June and then at the end of June Mr B fell twice on the same day. He went into hospital the next day when it was clear he was in pain.
19. For Mr B to be prevented from walking about would have required a separate decision making process that it was in his best interests to deprive him of his liberty in that way. The care plan included that staff should remind Mr B to use his stick and there was an alarm on the bedroom door to alert staff if he left the room in the night. I consider the home had put in place reasonable actions to allow him to walk around and there was no fault.
20. When Mr B fell on the day before he was taken into hospital I considered whether there was an appropriate response by the Home. An appropriate record was made of the incident and other notes show that Mr B ate well on the evening, watched television and slept well. There was nothing to show he was injured or in pain so there was no fault in the Home’s response to the falls.

Belongings

21. Mrs B complained that various items of clothing were lost including Mr B’s wedding ring. Mrs B said that she reported the loss of the ring to a member of staff at the Home when Mr B went into hospital and followed it up with her afterwards but had no response. In responding to the complaint the Care Provider agreed to refund the cost of the clothing but made no mention of the missing wedding ring.
22. The Care Provider is willing to consider making a payment so I would ask Mrs B to provide more information to the Care Provider on this point as to what she would see as an appropriate remedy.

Complaint handling

23. At the end of July Mrs B and other family members met with senior staff at the Home to discuss some of the concerns they had. The Home agreed to investigate and reply. That did not happen. This was fault and a missed opportunity to give a proper response to Mrs B and the family. Investigating close to when the events happened can give a much better response especially where such difficult issues are being considered.
24. When Mrs B complained a few months later the Care Provider did respond but there was no advice that the family could complain to us which is not good practice. But I accept the Care Provider’s comments that it did not consider the correspondence closed which is why there was no reference to next steps.

Agreed action

25. The Care Provider will, within a month of this decision, apologise to Mrs B for the failings found.
26. It will consider any information provided by Mrs B about the lost items and respond appropriately. If agreement cannot be reached then Mrs B can come back to us.

Back to top

Final decision

27. There was some fault which caused injustice to Mr B and Mrs B.

Back to top

Investigator's decision on behalf of the Ombudsman