Summary: the evidence does not show the actions of the care provider caused injustice to Mr D.

The complaint

1. Ms X (as I shall call the complainant) complains about the care and treatment of her late father Mr D at the care home. In particular she complains that he was left in a neglected state on one occasion, that the care provider did not keep proper records, that cream prescribed for another resident was used in his care and that his room was dirty.

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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)

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How I considered this complaint

3. I considered the written information provided by Ms X and by the care provider. Both Ms X and the care provider had an opportunity to comment on an earlier draft of this statement and I took their comments into consideration before I reached a final decision.

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What I found

4. 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.
5. Regulation 10 says service users must be treated with dignity and respect.
6. Regulation 12 says care and treatment must be provided in a safe way.

What happened

7. Mr D was admitted to the care home from hospital on 29 January 2020. He had dementia and needed assistance with personal care, hygiene and eating.
8. Ms X says when she and her mother (Mrs D) went to visit Mr D on 4 February at 09.50, they found Mr D lying across the bed, with a pillow over his face and dried vomit on him. They found a care worker who told them the night staff had not checked him before they left as they were short-staffed.
9. Later that day Ms X said she made a further unannounced visit to the home as she was so concerned by the earlier events. She says she was given different accounts by two different staff about whether or not Mr D had eaten lunch or taken medication, and she found the records of Mr D’s bowel habits incomplete .

The complaints

10. Ms X says she asked to speak to the manager about the incidents. The manager undertook to investigate. On 13 February the manager wrote to Ms X with an interim response. She said Mr D had been checked at 09.00 on 4 February when he was sleeping peacefully, and this was an acceptable timeframe for observations. She said the home was not short of staff, that the records showed Mr D had been checked overnight at suitable intervals and she was “disappointed” that incorrect information had been given. She said she would investigate further the allegation about failure to eat as Ms X was unable to identify which members of staff had said this.
11. Ms X raised further concerns. She said one of her father’s fingernails was missing and the nailbed left without a dressing. She said creams prescribed for another resident had been used for her father. A tablet had been found in his bed. She complained about the cleanliness of the room and bedding and said the bins were overflowing: she added she had photographic evidence.
12. Sadly Mr D died on 16 February.
13. The care home manager investigated the complaint, interviewing members of staff. She sent a detailed response to the complaint on 3 March. She said the nurse had already explained that no dressing was needed when Mr D’s fingernail came off. She said the creams which Ms X had found in Mr D’s room were new and had not been opened or used for anyone else (so there was no risk of cross-infection as Ms X had suggested). The nurses had used it as Mr D had very dry skin and the cream was spare. She said Mr D had a habit of either refusing medication or holding tablets in his mouth then spitting them out and in all likelihood, it was one of these which had been found. She asked to see the photographic evidence Ms X said she had of the room’s lack of cleanliness.
14. Ms X complained to the Ombudsman.
15. The care provider has provided copies of the daily progress notes which show that on 4 February Mr D had a chest infection. He had not vomited but had cleared his chest by coughing.
16. The care provider says the photographic evidence provided (which she has sent to me) does not bear out the allegations made by Ms X about a lack of cleanliness. The beaker Ms X photographed is not one supplied by the home, nor is the blanket on which there is a small dirty mark. She says the photos of bins in Mr X’s room showed a bin which was full but not overflowing, and on the next day the bin was full with other products, showing it had been emptied in the interim. Ms X maintains the standard of hygiene at the home was poor.
17. Copes of the Medication Administration charts have been supplied by the care provider and show when Mr D refused his medication: this is also charted in the daily progress notes.
18. The care provider has also supplied copies of her notes of the investigation into why Ms X was told the home was short-staffed. The care worker who spoke to Ms X acknowledged she should have called a member of the nursing staff to speak to the family but had simply offered an opinion without knowing the facts.
19. The manager contacted the local council safeguarding team about Ms X’s concerns over the cream used for Mr D. No action was taken. The manager says she also held a reflective meeting with the nursing staff and found the decision to use the cream had been taken in Mr D’s best interests.

Analysis

20. It is understandable Ms X was concerned when she saw her father on 4 February. However there is no evidence staff had failed to check on him or that he was at risk.
21. Some unguarded remarks by a member of staff concerned Ms X, but without foundation.
22. The safeguarding team saw no reason to take action on the use of the cream.
23. In any event, there is no evidence Mr D’s care was affected by the points Ms X raised.

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Final decision

24. The care provider’s actions did not cause injustice to Mr D.

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Investigator's decision on behalf of the Ombudsman