Summary: Mr X complained about the care his late mother Mrs F, received at Melbury Court care home (the care provider) between February and July 2019. The care provider was at fault. The care provider failed to adequately administer Mrs F’s pain relief and failed to address her regular refusal of personal care. The care provider agreed to pay Mr X £250 to acknowledge the distress and uncertainty caused to him by the faults.

The complaint

1. Mr X complained on behalf of his late mother, Mrs F, who lived at Melbury Court care home (the care provider) between February and July 2019. Mr X complained:
• Mrs F did not receive an adequate standard of personal care.
• The care provider failed to adequately monitor Mrs F’s food and fluid intake.
• The care provider failed to adequately administer Mrs F’s prescribed pain medication.
• Mrs F’s personal belongings were damaged and went missing.
2. Mr X said Mrs F suffered unnecessary distress due to the overall poor standard.

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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. 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 an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
6. If we are satisfied with an adult social 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)
7. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

8. I spoke to Mr X about his complaint and considered information he provided.
9. I considered the care provider’s response to my enquiry letter and the information it provided.
10. I considered the CQC’s ‘guidance for providers on meeting the fundamental standards’.
11. Mr X and the care provider had an opportunity to comment on my draft decision. I considered comments before I made a final decision.

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What I found

Fundamental Standards of Care

12. 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.
13. Regulation 9 is about person centered care. It says care providers should carry out an assessment of a person’s needs and develop a clear care plan. The care and treatment should be designed to meet the person’s needs.
14. Regulation 12 is about safe care and treatment. It says it should carry out timely administration of medication and carry out regular reviews.
15. Regulation 14 is about making sure that people who use services have enough to eat and drink to meet their nutrition and hydration needs and receive the support they need to do so.
16. Regulation 17 is about good governance. It says a care provider should “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided”.

What happened

17. Mrs F had dementia and moved into the care home in February 2019. The records show Mrs F also had peripheral vascular disease (PVD) in her legs which Mr X said made it difficult for her to walk.
18. Mrs F’s care plan showed she required support with personal care. It said she may refuse help but staff should keep going back and trying again. The plan said staff should weigh Mrs F monthly but more frequently if there were any concerns. The plan included a risk and falls assessment and a mobility plan which were regularly updated. Records show Mrs F’s doctor provided the care provider with details of Mrs F’s medication which included pain medication to be given as needed when she moved into the care home. Records show Mrs F received care from doctors, nurses and staff for wounds to her legs caused by PVD.
19. The care home daily records show Mrs F settled well into the care home. They show however that Mrs F regularly refused assistance with personal care and going to bed. However, they show she was generally content and there were no overall care concerns.
20. Mr X started raising concerns about Mrs F’s care in March 2019. He said he reported that some of her personal items were missing including her false teeth which staff found in another resident’s room. Mr X said he found one of Mrs F’s photo frames broken with glass still on the floor. He also reported her shaving equipment and her dementia clock were missing. Mr X said he regular visited Mrs F and found her in other resident’s rooms and sometimes other resident’s lying in her bed. Mr X said he was asked to submit his comments to head office via an electronic screen in the reception area.
21. In June 2019, the doctor visited Mrs F and admitted her to hospital for a swollen leg. Mrs F’s other son, Mr Y, took her to hospital along with medication charts from the care home. Staff at the hospital told Mr Y the care home had not been providing Mrs F with her pain medication on a regular basis. Mr X said he raised this issue with care home staff who said they were trained in identifying pain so would give medication when required. Mr X said it was obvious Mrs F was in pain. The doctor changed Mrs F’s medication so the care home should administer it regularly.
22. Mr X said Mrs F’s weight started to reduce from June onwards following her admission to hospital. Mr X said on one day he visited Mrs F mid-morning and found her wet and soiled in bed. Mr X said he had to tell staff to get her dressed and give her clean bed sheets.
23. The records show the care home put Mrs F on a fortified diet and her weight chart showed her weight increased after admission. However, in July 2019 Mr X said Mrs F became noticeably thinner and the weight chart showed a rapid weight loss. The care home responded to this by contacting the doctor and in line with her care plan it started monitoring her food and drink intake. The doctor recommended the care home keep nutrition charts but observed her to be well generally.
24. At the end of July 2019 Mrs F was admitted back into hospital for treatment for an infection, dehydration and malnutrition. Mrs F died at the end of July due to an infection caused by her ulcerated legs.
25. Mr X complained to the care home. He said Mrs F was caused unnecessary pain and suffering due to the care home not meeting her needs.
26. The care provider sent Mr X its initial response to his complaint in September 2019. It said it was evident the care home had not addressed Mrs F’s pain management well, specifically in relation to pain relief prior to dressing her legs. It said it was satisfied it addressed this in June 2019, at which point Mrs F’s pain medication was prescribed on a regular rather than ‘as needed’ basis. The care provider apologised Mrs F’s personal items had gone missing in the care home and said it would carry out a search for the items. The care provider said Mrs F regularly refused help with her personal care. It said however it should have discussed this with Mr X and should not have simply accepted it. In relation to Mrs F’s food and fluid intake the care provider said she seldom did not meet fluid targets. The care provider apologised about the lack of response from the care home manager in response to Mr X’s concerns. It also apologised for not sending a condolence card upon Mrs F’s death.
27. The care provider said it had reviewed its staffing following Mr X’s complaint and was carrying out regular training. It said it had also made it clear to its staff not to just accept refusal of care without taking action to resolve it. It said it would reimburse Mr X for Mrs F’s lost possessions if he provided it with a list of the items and the value.
28. Records show Mr X queried further Mrs F’s food and fluid intake and asked why there was a lack of records in relation to it. The care provider said there was no clinical need to record this as Mrs F ate and drank well. Mrs F’s weight chart showed her weight and BMI increased between her admission in March 2019 and June 2019 before she started losing weight.
29. Mr X remained unhappy with the care provider’s response and complained to the Ombudsman.

My findings

Record keeping

30. The records show the care home kept a thorough and detailed care plan for Mrs F’s needs which it regularly updated. It had a risk assessment for falls and a mobility plan. It kept records of its contact with Mrs F’s doctor and records show it checked on Mrs F during the night on regular occasions. It kept appropriate daily care records which noted Mrs F’s personal care, medication and nighttime routines.

Mrs F’s pain relief medication

31. The care provider has accepted it did not deal with Mrs F’s pain management very well prior to June 2019. The care home was aware of Mrs F’s medication when she moved in. Records show Mrs F received regular dressings for her leg wounds prior to June but the records show the care home rarely gave her pain relief medication. Mrs F was administered pain relief on an ‘as needed’ basis but there is no evidence the care provider properly considered whether she was in pain. It is likely, on balance, that Mrs F suffered unnecessary pain due to the provider’s poor management of her medication. This failure is not in line with regulation 12 of the fundamental standards and is fault.

Mrs F’s personal care

32. The daily care records show Mrs F regularly refused personal care and regularly refused to go to bed in her room. She had dementia therefore I would have expected to see records of various techniques used. There are no records to show how the care provider addressed these issues which is not in line with regulation 9 of the fundamental standards and is fault. The care provider has accepted that staff at the care home should not have simply accepted this It caused Mr X uncertainty over whether the care provider met Mrs F’s personal care needs as it should have done.

Mrs F’s nutritional and fluid intake

33. There is no specific obligation for the care provider to record daily food and fluid intake unless circumstances dictate. The care provider kept records on her admission and again from June 2019 onwards following advice from the doctor in response to Mrs F’s weight loss. It regularly weighed Mrs F and monitored her body mass index and responded appropriately by contacting the doctor when she started losing weight. The records also show the care home provided Mrs F with supplementary milkshakes to maintain her weight. Therefore, I am satisfied the care home properly monitored Mrs F’s nutrition and fluid intake and responded appropriately to her weight loss in line with her care plan.

Injustice

34. I cannot remedy the injustice the identified faults caused Mrs F. Its failure to address Mrs F’s regular refusal of personal care and adequately administer her pain relief caused Mr X distress and uncertainty. I have therefore made recommendations to the care provider to remedy this injustice.
35. The care provider has shown us evidence of training it has carried out since Mr X’s complaint. It enrolled all staff at the care home on a training course to help staff support residents with dementia. The training included elements on responding to and supporting residents who refuse personal care. The training also included identifying verbal and non-verbal indicators to identify when residents are expressing pain. The care provider said it has assessed all staff as competent in administering medication. This is an appropriate response following the faults identified from Mr X’s complaint.

Agreed action

36. Within one month of the final decision the care provider agreed to:
• pay Mr X a symbolic payment of £250 to acknowledge the distress and uncertainty caused to him by the its failure to address Mrs F’s refusal of personal care and for failing to adequately administer her pain relief.

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Final decision

37. I have ended my investigation. There was fault causing injustice and the care provider agreed to my recommendations to remedy that injustice.

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Investigator's decision on behalf of the Ombudsman