Summary: the complainant complained the Care Provider provided poor quality care for her mother at its Britten Court Lowestoft care home causing distress and risk of harm. The Care Provider says it learned from the complaint by improving staff practice and engaged with the proper agencies to report safeguarding issues. We found following several falls and some incidences of poor care the Care Provider caused injustice for which we have recommended a remedy.

The complaint

1. The complainant whom I shall refer to as Mrs X complained the Care Provider caused injustice to her mother, Mrs Y. Mrs X says the Care Provider failed to properly care for Mrs Y over two years in the Care Provider’s home Britten Court, Love Road, Lowestoft NR32 2NY. Mrs X says the Care Provider failed to provide proper personal care, prevent injury to Mrs Y or preserve Mrs Y’s’ dignity.
2. Mrs X says this caused Mrs Y and her family distress. Mrs X wants the Care Provider to improve its complaints procedure and supervision of personal care to prevent this happening to anyone else. Mrs X wants the Care Provider to refund some of the fees charged for the care provided in recognition of the injustice caused.

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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. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
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. 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)
7. 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.

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How I considered this complaint

8. In considering this complaint I have:
• Spoken to Mrs X and read the information presented with her complaint;
• Put enquiries to the Care Provider and reviewed its response including care notes from April 2018;
• Researched the law, guidance, and policy;
• Shared with Mrs X and the Care Provider my draft decision and reflected on the comments received before making this final decision.
9. Under our information sharing agreement, we will share our final decision with the Care Quality Commission (CQC).

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What I found

The law, guidance, and policy

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations) set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) issued guidance (the Guidance) in March 2015 on how to meet the fundamental standards below which care must never fall.
11. The Regulations set out the fundamental standards care providers must always observe.
12. The Regulations impose a duty on the care provider to provide care that is:
• Person-centred;
• Ensures the resident’s dignity is preserved and they are treated with respect;
• Safe;
• Meets the resident’s nutritional and hydration needs;
• Reviewed in line with the complaints’ procedure.

What happened

13. Mrs Y moved into Britten Court in October 2017, aged 94. Mrs Y needed help with personal care, medication, and eating. The case notes show Mrs Y received daily personal care and this would include washing, oral hygiene, application of creams, nail cutting, and staff recorded Mrs Y’s mood and health. Due to her risk of falling while in bed staff placed the bed at its lowest position. They also placed crash mats next to the bed and switched on the alarm used to alert staff should Mrs Y fall from the bed. Records show Mrs X said she would attend to Mrs Y’s nails, but she says the family only decided that because of concerns about the nail care provided.
14. From January 2018 Mrs X raised concerns on several occasions about Mrs Y’s care. These included staff not waking Mrs Y up, ensuring she had breakfast, and making Mrs Y wait too long for a standing aid. Mrs X complained staff left Mrs Y in bed for too long, failed to prevent falls from the bed and had occasionally not changed soiled bedding or cleaned her room.
15. In February 2019 staff recorded that during personal care they accidentally caused bruising to Mrs Y’s face with the belt of the sling. Bruising also occurred due to her positioning on her bed. Care notes record Mrs Y rolling out of bed onto the crash mats in February, April and September 2019 with Mrs Y calling out for help. Through July and August 2019, the Care Provider records Mrs X raising concerns about care with the Care Provider.
16. In August 2019 Mrs X complained a carer serving Mrs Y with a meal did so with a sandwich in the carer’s mouth. Mrs X said this showed a lack of respect for Mrs Y. The Care Provider disciplined the staff member. Mrs X also complained the home did not have enough cutlery. Residents had to wait until others had finished so staff could clean it and give it to residents waiting to complete their meals. Mrs X said on some occasions staff had not cleaned or tidied Mrs Y’s room leaving the bed unmade, with soiled bedding on the bed and soil marks on the carpet. In commenting on my draft decision, the Care Provider says it offered to change the floor covering to vinyl or replace the carpet having shampooed and cleaned it to remove stains.
17. Mrs X says during Mrs Y’s two year stay at Britten Court she experienced constant worry about whether Mrs Y would receive proper care. Mrs X says unexplained bruising occurred in April 2019. Mrs X says this happened again in November 2019. Mrs X says this was the final incident that led her to move Mrs Y to a new care home. Mrs Y had unexplained bruising on her legs. The Care Provider says Mrs Y did not display any wounds or bruising on her legs when carers dressed her and prepared her for a day out with her family. However, on her return when undressing and preparing for bed, carers noted the bruising. The Care Provider told the agency nurse, the MASH and SOVA groups. When told the GP sent out a nurse practitioner to check Mrs Y. The GP believed a burst blood vessel caused the bruising. The Care Provider reported the incident to CQC under Regulation 18(2) of the Care Quality Commission (Registration) Regulations 2009.
18. The accident and incident forms completed by the Care Provider show several incidents including falls between March 2018 and November 2019. These included occasions when Mrs Y slipped or fell from her chair in the resident’s lounge or from her bed in her room. On assessment in October 2019 the Care Provider found Mrs Y had significant risk of trapping herself if staff installed bed rails. Therefore, the Care Provider placed a crash mat almost level with the height of the bed and a lower one next to that to reduce the risk of injury if Mrs Y rolled out of bed. The Care Provider placed under the mat an alarm triggered by Mrs Y’s body weight if she fell onto the mat. When commenting on my draft decision the Care Provider explained placing a bed at the lowest position with crash mats to enable the resident to roll out of the bed is common industry practice. Someone rolling out of bed is not considered a fall from bed and so would not be reported to the family or next of kin.
19. Case notes show carers undertaking personal care. However, Mrs X says she and other family members had to constantly help clean Mrs Y’s hair, nails, and teeth. She says they had to follow up other health and care issues with the Care Provider. Although care improved for a time following complaints Mrs X says the standards would soon fall away again. Since moving Mrs Y to a new care home, Mrs X says Mrs Y has not faced these problems. This Mrs X says has highlighted what she believes is the poor care offered by the Care Provider.
20. Mrs X says Mrs Y paid £1000 a week but received a poor standard of care. Mrs X wants the Care Provider to refund some of the fees in recognition of the poor service. Mrs X wants the Care Provider to improve quality monitoring to ensure every resident receives a consistently good standard of care.
21. The Care Provider says it examined Mrs Y’s complaints and made changes where necessary. The Care Provider says CQC reports suggest Britten Court provides good quality care and it has not received other complaints.

Analysis – did the Care Provider cause an injustice?

22. Our role is to consider if the Care Provider properly supervised care for Mrs Y in line with the expectations set out in the Care Plan and the contract governing her stay at Britten Court. If it did not, causing her an injustice, we must consider what the Care Provider should do to address that injustice.
23. Over eighteen months, the accident and incident chart show several entries. The case notes show Mrs X complained many times about the care received. Mrs Y experienced several falls from her bed and from a chair. The case notes often record Mrs Y as happy, with no concerns from staff and that staff have completed her personal care. The records show the Care Provider told next of kin about incidents, reported them to the safeguarding authority and engaged help from the NHS 111 service, local GP, and practice nurse.
24. Any fall involving someone of Mrs Y’s age is likely to result in injury. To avoid injury the Care Provider had in place crash mats and alarms in line with industry practice. The Care Provider followed guidance on alerting authorities to any injuries. That said the number of falls creates the impression for the family that Mrs Y remained at risk of harm and experienced harm from the falls. Any lack of personal care and rapid changes of clothes when necessary touches on the resident’s dignity and well-being.
25. I have not listed in this statement all the incidences of poor care or customer services alleged by Mrs X. Records show several occasions when the service fell below the standard Mrs X and Mrs Y had the right to expect. Having noted the Care Provider’s action to improve staff performance and training, and apology for failings I must decide if that is enough to allay the distress caused. The case notes and complaints do not suggest consistently poor care. However, the number of falls, and occasional lapses of care caused Mrs X avoidable concerns. Three falls resulted in Mrs Y calling out for help before staff found her on the crash mat, due to the absence of an alarm or one that did not trigger. These caused fear of risks of harm to Mrs Y, when staff delivered inconsistent care. Therefore, I find the Care Provider did not always provide consistently good care and this caused avoidable distress and placed Mrs Y at risk of harm.
26. The charges levied for Mrs Y’s care are a matter of contract law between Mrs X and the Care Provider. I have found incidences of poor care and avoidable distress, but I cannot decide what proportion of the care provided this affected or whether the Care Provider should refund any care charges. The courts can decide if one party has not fulfilled their part of a contract and what damages a party should refund. Our Guidance on Remedies sets out what symbolic payments we recommend in recognition of injustice. This includes avoidable distress and risks of harm or incidences of harm any poor care caused. Applying that guidance, I recommend a payment to Mrs X in recognition of the distress caused, the inconvenience in undertaking personal care when it had not been given, and the risk of harm or injury caused by Mrs Y’s falls.

Recommended action

27. I recommend the Care Provider within four weeks of my final decision pays Mrs X £1,500 in recognition of the avoidable distress and inconvenience caused by lapses in the care service provided to Mrs X. The payment also recognises the risk of harm to Mrs Y from falls and any lack of personal care.

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Final decision

28. In completing the investigation, I find the Care Provider caused injustice and therefore we are issuing this statement recommending a payment to Mrs X.

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Investigator's decision on behalf of the Ombudsman