Summary: Ms X did not have a written care plan setting out her care needs. This meant the service to her was not in line with care regulations applicable in care homes. The Care Provider will apologise, make payments and ensure all new residents have care plans on admission.

The complaint

1. Ms Y complains for her mother Ms X about one of the Care Provider’s care homes, Tara’s Retreat (the Care Home). Ms Y says:
1. Ms X spent her first night in a chair because the mattress was too low so she could not get in and out of bed. Carers did not help Ms X to get in and out of bed throughout her stay
2. She was not encouraged to attend activities
3. Staff did not administer water tablets or remind her to elevate her legs
4. A hairdresser’s appointment was not arranged
5. Ms X developed a cough due to poor hygiene
2. Ms Y says her mother received a poor service and would like a refund of the fee.

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What I have investigated

3. I have investigated complaints (a) to (c). My reason for not investigating the other two complaints is at the end of this statement.

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The Ombudsman’s role and powers

4. 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. (Local Government Act 1974, sections 34B and 34C)
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 considered the complaint to the Ombudsman, the Care Provider’s complaint response and documents set out later in this statement.
7. Ms Y and the Care Provider 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

Law and guidance

8. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) The Ombudsman considers the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
9. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.

What happened

10. Ms X came to the Care Home for a week of respite care in January 2020 after a fall at home. Ms Y told us the purpose of the stay was for Ms X to regain confidence after the fall and for her to relearn how to get in and out of bed safely and independently.
11. The Care Home’s contract, which Ms Y signed, said:
• All residents would have a comprehensive assessment of care before admission.
• A care plan would set out in detail the action needed for care staff to take to meet the resident’s care needs.
12. Before Ms X’s stay, Ms Y gave the Care Home a written description of Ms X’s care needs and her daily routine. Ms Y explained her mother needed to elevate her legs when possible. She said staff would need to support Ms X to re-learn how to get in and out of bed safely and described how Ms X usually got herself in and out of bed at home.
13. There was no assessment or care plan for Ms X.
14. The Care Home kept electronic case notes of the care staff provided to Ms X. The case notes for the first night say a carer helped her put on nightclothes and to get into bed. The same member of staff later helped Ms X to the toilet. The carer noted Ms X did not want to go back to bed after using the toilet and so she was helped into a chair. The notes indicate Ms X was content to remain in the chair for the rest of the night and said she did not want to go back to bed.
15. The following day, staff arranged for Ms X to have a different mattress as the existing one was too low for her.
16. Ms Y also emailed a member of staff to say she was not happy Ms X was not receiving guidance from staff on how to get in and out of bed safely and that two nights into her stay, she was sleeping in a chair and not in a bed.
17. The case notes indicate Ms Y did sleep in the bed most nights following the change of mattress. She is described as being settled in bed on one occasion at night and there are several entries saying she was helped to get into bed and to the toilet at night and then back into bed. On another occasion, Ms X was sitting in her chair during part of the night and was awake and content.
18. One case note says a member of staff gave Ms X a foot stool to elevate her legs. There is no further information about whether staff encouraged Ms X to use the foot stool.
19. Staff kept a medicine chart which they signed when giving Ms X her medicines. The chart for Ms X’s daily water tablet is fully completed.
20. Ms Y spoke to a member of staff and said her mother was shy and would need help to make friends. The notes indicate Ms X went to the day centre and on an unspecified outing during the week of her stay at the Care Home.
21. Ms Y complained to the Care Provider. It responded to the complaint and provided a part refund because Ms X left the Care Home a night early. The Care Provider also said it would review the information it shared with families before admission to ensure all were clear about expectations.

Findings

Complaint a: Ms X spent her first night in a chair because the mattress on her bed was too low so she could not get in and out of bed and carers did not help Ms X to get in and out of bed throughout her stay

22. The Care Provider should have had a written care plan describing in detail the support Ms X needed to get in and out of bed. It was inappropriate to rely on the information Ms Y provided. The Care Provider should have devised its own care plan to meet Ms X’s needs having discussed expectations with both Ms X and Ms Y. The service to Ms X was not in line with Regulation 9 of the 2014 Regulations or in line with the written contract because staff had no care plan to refer to and so did not know how to support Ms X to transfer to and from the bed. This was despite Ms Y stressing it was important for Ms X to re-learn this skill. I uphold this complaint.
23. The Care Provider acknowledged the mattress was inappropriate for Ms X and changed it without delay. This is an appropriate action in response to the concern raised about it being too low.

Complaint b: Ms X was not encouraged to attend activities

24. Ms X should have had a care plan setting out her needs in this area. The lack of a care plan meant care was not in line with Regulation 9 or the contract. I note Ms X was in the Care Home for a week of respite care, and she did go out to the day centre and on another outing. So I cannot see she suffered significant injustice. I do not uphold this complaint.

Complaint c: Staff did not administer water tablets or remind Ms X to elevate her legs

25. There should have been a written care plan setting out Ms X’s needs in this area and directing staff to encourage and remind Ms X to use the foot stool. There is no evidence staff reminded Ms X to elevate her legs. The failure to have a written care plan means the service to Ms X was again not in line with Regulation 9 or the contract. I uphold this complaint

Agreed action

26. The Care Provider should have had written care plans for Ms X. It did not matter that her stay was a short one, the 2014 Regulations apply for short stays.
27. Ms Y suffered avoidable time and trouble in complaining and Ms X did not receive a service in line with a care plan tailored to her needs. To remedy the injustice, the Care Provider should:
• Make Ms X symbolic payment of £150 to reflect the lack of a tailored care plan
• Make Ms Y a payment of £100 to reflect her time and trouble complaining
• Apologise for the failure to provide a written care plan
• Ensure staff always complete care plans for all new residents, including short-stay residents.

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Final decision

28. Ms X did not have a written care plan setting out her care needs. This meant the service to her was not in line with care regulations applicable in care homes. The Care Provider will apologise, make payments and ensure all new residents have care plans on admission. It will take these actions within one month of this statement.
29. I have completed the investigation and shared a copy of this statement with the Care Quality Commission in line with our information sharing agreement.

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Parts of the complaint that I did not investigate

30. I did not investigate complaints (d) and (e) because there is not enough injustice to Ms X or Ms Y.

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Investigator's decision on behalf of the Ombudsman