Summary: Mrs C complained about the care her (late) mother received while she stayed at the care home. We found there was fault with regards to some of the actions of the care provider, for which the care provider has agreed to apologise. It will also provide a financial remedy for the distress Mrs C experienced and will share the lessons learned with care home staff.

The complaint

1. The complainant, whom I shall call Mrs C, complained to us on behalf of her late mother, whom I shall call Mrs M. Mrs C complains the care home in which her mother stayed, failed to:
• Prevent, and appropriately respond to, a fall in July 2019.
• Ensure that her mother’s toenails were cut regularly by her Podiatrist.
• Provide sufficient and correct care when washing and drying her mother’s groin, which made it sore, red and bleeding.
• Clean her mother’s hands and nails.
• Assist her mother with cleaning her teeth.
• Regularly respond to the call button in an appropriate manner.
• Prepare her food appropriately.
• Provide personalised care by giving her a banana every morning with her cup of tea, as requested.
• Look after her mother’s clothes, which went missing even when they were labelled.
• Minute the meetings they had with the home to discuss concerns around care.

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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)
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. 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 34H(i), as amended)

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How I considered this complaint

5. I considered the information I received from Mrs C and the care provider. I shared a copy of my draft decision with Mrs C and the care provider and considered any comments I received, before I made a final decision.

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What I found

Relevant legislation and background

6. 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. We consider the 2014 Regulations and the Fundamental Standards, as well as a provider’s policies and procedures, when determining complaints about poor standards of care. The following regulations are relevant to this complaint:
7. Regulation 9 (Person-centred care) says each service user should receive care that is personalised specifically for them, that meets their needs and reflects their preferences.
8. Regulation 12 (Safe care and treatment) says care providers should prevent service users from receiving unsafe care and treatment, in order to prevent any avoidable harm or risk of harm. It includes the requirement to exchange information where responsibility for the care and treatment of service users is shared with, or transferred to, other persons (in this case the ambulance service).
9. Regulation 14 (Meeting nutritional and hydration needs) includes a requirement to ensure that food can easily be consumed (the service user can eat it regardless of any limitations they may have). A service user should also have appropriate equipment/tools to help them eat independently.
10. Regulation 17 (Good Governance) includes a requirement to record all feedback received from service users.

The complaint about the fall in July 2019

11. Mrs M went into the care home (Kingston House in Derry Hill) in November 2018. This was initially meant for a two-weeks period. However, she concluded at the end of the two weeks that she would not be able to cope at home anymore and decided to make the placement permanent.
12. Mrs C says the care home failed to prevent her mother’s fall on 11 July 2019. She says:
• Her mother had a near fall earlier that day, when she and a family member visited her mother. Her mother was returning from the toilet when her legs gave way. She subsequently used the emergency button to alert staff.
• She told the staff member who arrived about the near miss and asked the staff member to ensure the home would keep a close watch on her when mobilising. She asked to ensure she would inform other staff members as well.
• Mrs C says she also told a senior carer that day, so that:
1. Other staff and the night staff would be aware of this.
2. Staff would keep a close eye on her and assist her when transferring (to and back from the commode).
13. However, Mrs C says that neither staff member documented this information on the handover notes. As such, the night staff were not informed of what had happened. This meant that, when her mother tried to mobilise from the commode back to her chair in the evening, she did not get the support she should have received. She fell and was admitted to hospital with a fracture.
14. Mrs M’s pre-admission assessment form says:
• Able to weight bear.
• I use a frame to help me mobilise short distances.
• Uses her riser recliner to aid standing.
• It did not tick “I am able to safely independently mobilise with / without equipment” or “I require the support of one carer”.
15. The care home says that it carries out a falls risk assessment for all new residents, which it reviews monthly. Mrs M’s falls assessment from December 2018 says she is low risk. The records show the home reviewed all care plans every month.
16. Mrs M’s continence care plan says: continues to be supported as she likes, and later says continues to manage her continence etc. Mrs C says her mother’s continence was managed with support throughout, which means the care plan was not accurate during the later stages of her stay.
17. Mrs M’s mobility care plan includes all the information from her pre-admission assessment and was reviewed monthly.
18. Manual handling assessment from January 2019 says:
• Can mobilise to the toilet using a frame.
• Independent with transferring in/out of bed but chooses not to sleep in her bed.
19. The care provider says:
• It was not aware of any deterioration in Mrs M’s ability to mobilise, on the day of her fall. The staff member that Mrs M said she spoke to, denied having responded to Mrs M’s call bell.
• Staff usually record the outcome when they respond to a call bell. If the call bell is used because someone is unwell, staff would record this in the individual resident’s daily log. We have no evidence that the family used the call / emergency bell and made any staff member aware of a near miss fall that day.
• This is the first time that Mrs C says she used the “emergency call bell”.
20. Mrs C says the above statement is incorrect. She says an accident report mentioned that Management told the afternoon senior carer that Mrs M appeared overly tired throughout the day. The Senior said she would monitor Mrs M throughout the shift.
21. Mrs C also says that a care worker was with her mother when the fall happened. However, she failed to prevent it. She says the care worker should have assisted her mother with transferring back from the commode to her chair. If she had done so, this fall could have been prevented.
22. In response, the care provider told me that:
• Mrs M had a care plan in place to monitor and manage her mobility. Staff assisted with mobilising including when accessing the toilet/commode. She did not have any previous falls.
• A member of staff was assisting Mrs M back to her chair, when her leg gave way under her without warning. All moving and handling training state its standard practice that care workers should not try to catch a falling resident, but instead guide them as safely as possible. This is what the carer did.
23. Mrs M says that the care worker who was present, said in her statement that her mother’s “leg seemed lazy and she started shouting that she would fall”.
24. The incident report said: A staff member supported Mrs M onto the commode. As Mrs M stood up, she said she had pain in her leg and suddenly lost balance as she went to sit down on the chair. She slipped of the chair and landed on her right leg on the floor.
25. Mrs C says it is difficult to understand how the care worker could not have supported her mother when her leg gave way, if the care worker was beside her at the time. She says her mother always used a walking frame in her room; her chair and commode were at right angles to each other. There would therefore have been little room for her not to be supported in these circumstances.
26. Mrs C complained that the care home also failed to properly respond to the fall and had lied about certain events. The following is an overview of the relevant information related to the events that happened after the fall:
• The care home (staff member X) spoke to Mrs C’s sister at 10.30pm, to say Mrs M had fallen. The call got cut and her sister called back at 10.45pm. Her sister offered to call an ambulance, but staff member X said she had already done this. However, it was confirmed at the inquest from the 999 Incident Report that the care home only called at 11:03. As such, it was not true what staff member X told Mrs C’s sister.
• Mrs C said the care worker who had been with Mrs M when she fell, reported hearing a loud crack. Her mother was also in extreme pain afterwards. Even so, staff member X moved her mother’s leg from underneath her, which is against advice/guidance on how to respond to such falls. Staff member X told the family, during the call at 10.45pm, that she moved the leg after discussing it with the ambulance service. However, this was not possible, because according to the ambulance records, this call was only made at 11:03. As such, this statement from staff member X was not true.
• The recording from the ambulance service confirmed the first call was made at 11:03 and staff member X said the fall happened about 15 minutes ago. She said Mrs M had fallen from the chair onto the floor on her way to the toilet. During a fifth call she said it happened when a staff member helped Mrs M onto the commode. During the second call, staff member X said she moved the leg that was trapped underneath, because ‘she could not leave her in that position’. She also mentioned that staff had heard a crack. However, this would also happen at times she mobilises. During the calls, staff member X said Mrs M was in a lot of pain and the officers stressed not to move Mrs M.
• Staff member X later stated she decided to reposition Mrs M, because she was uncomfortable on the floor, becoming increasingly agitated and trying to move without assistance. She was also concerned about her blood supply to the leg with the position that Mrs M was in.
• During each call, the ambulance service would ask if there was any serious bleeding. Staff member X said no each time, however failed to explain that Mrs M was at risk of internal bleeding due to her medication.
• Staff member X said during the fifth call that she had though about calling an out of hours doctor to give pain relief. However, the ambulance clinician said they would not have done that as Mrs M had an injury.
• Mrs C says the paramedics asked the home what pain relief Mrs M had received. Staff member X said nothing had been administered, even though she had been in pain. However, the care provider says Mrs M had received her last pain relief at 9:15pm and staff were not allowed to give more because she had received the maximum dose allowed over a 24-hour period. It said: “Advice was requested by the ambulance service and followed accordingly”.
• Staff member X also failed to tell the paramedics that her mother was taking medication that could cause internal bleeding in the event of a fall. The care provider has since said it has done some work with its staff to make them more confident in dealing with the emergency service and identify information that is important to hand over.
27. The care provider told me that:
• The incident report was not properly completed. Staff member X failed to record what actions had happened at what specific times. As such, it appeared that all actions happened at 10.30.
• Staff now have clear instructions to give all medical history and medication details as a matter of course. This is now part of the documentation used in the home to record action taken during an accident/fall etc.

Analysis

28. Mrs C says she spoke to two staff members after her mother had a near fall on 11 July 2019. I can see no reason why she would have been untruthful about that. I found that, on the balance of probabilities, Mrs C told (at least one) staff member to keep an eye on her mother and pass on the information to other relevant staff. However, the staff member did not ensure this information was passed onto the night team, which was fault. However, I am unable to conclude this would have resulted in a different outcome, because Mrs M was supported by a staff member when she transferred during toileting. There is no evidence to conclude the fall happened due to inappropriate support by the staff member during the transfer.
29. Based on the available evidence, I also found that the care home:
• Did not tell the truth when it said an ambulance had already been called.
• Did not tell the truth when it said it moved Mrs M after the ambulance service agreed it could.
• Failed to discuss, with a medically qualified professional, whether it should move Mrs M, before doing so.
• Failed to tell the ambulance service that her mother was taking medication that could cause internal bleeding in the event of a fall.
30. This was not in line with Regulation 12 of the Health and Social Care Act.

The complaint about Mrs M’s toenails

31. Mrs M’s pre-admission assessment form says that District Nurse were dressing ulcers on both of her legs with bandages.
32. Mrs C says that:
• When her mother got admitted to hospital in July 2019 after her fall, the nurses in the hospital showed them the appalling condition of her mother’s feet. She said her mother’s toenails were so long they had actually grown underneath her toes and were digging into the underside of her feet. In between her toes, the skin was raw and bleeding.
• This happened, because the care home failed to ensure her mother’s toenails were regularly cut by her Podiatrist. The District Nurses had put a leg and foot bandage that covered Mrs M’s toes. This prevented the Podiatrist from cutting the toenails. However, the care home should have tried to come up with a solution with the health professionals involved. Perhaps they could have coordinated the visit of the Podiatrist, with the visit by the District Nurses responsible for replacing her leg and foot bandage. This would have enabled the Podiatrist to attend to her toenails when the bandage was removed / changed.
• As a result, her mother’s toenails grew so long that it made her / walking uncomfortable and painful. It was recorded that the district nurses had asked the home a number of times to arrange for the podiatrist to call.
33. According to the records: The home made a phone call on 15 March 2019 to cancel Mrs M’s upcoming podiatry appointment ‘as patient has both legs and feet in plasters’. The home requested discharge from podiatry as ‘the patient will be in bandages for months.’ Discharged from podiatry as requested.
34. The care provider told me that the District Nurse regularly visited Mrs M to care for her legs and feet, including washing and creaming. It said that at no point did the District Nurses raise a concern about Mrs M’s toenails with the care team. However, a record from 22 April 2019 states a district nurse asked the home to arrange for Mrs M’s toenails to be cut as ‘left foot 4th toenail curling under and pressing into bottom of foot’.
35. However, it took until 28 June 2019 before the records state: “NHS Podiatrist contacted and will visit 17 July to cut her toenails. If bandage is covering toenails, ask DN to come and remove it”.

Analysis

36. In March 2019, the care home cancelled Mrs M’s Podiatrist appointments for the next few months, because her feet would continue to be covered by bandages. However, the care home failed to realise what problems this would cause with regards to Mrs M’s toenails growing etc. Furthermore, it was told in April 2019 by a district nurse to organise podiatry visits again. However, the care home failed to do this quickly enough.
37. It would have been possible to cut Mrs M’s toenails, if the care home had tried to coordinate the visits from the Podiatrist and the District Nurses. It was for the care home to take an active role in this. However, it failed to do/try this. It resulted in Mrs M’s toenails growing very long and becoming very uncomfortable, especially when moving around.
38. The fact that Mrs M did not receive the care she needed, with regards to this aspect, is not in line with Regulation 9 of the Health and Social Care Act.

The complaint about Mrs M’s groin area

39. Mrs C says:
• Her mother would sometimes complain she was sore in her groin area, which the family would report to the care staff and the management. However, the home did not do anything to address this.
• Nurses at the hospital told her on 12 July 2019 that her mother had a sore groin which was red and bleeding. The nurses said this was due to her mother receiving insufficient and incorrect care when washing and drying this area.
40. The care provider said in its response on 3 October 2019 that:
• Mrs M was seen by the GP on several occasions regarding her skin integrity, who prescribed several creams. The last record with regards to this is from March 2019 and says the GP prescribed ProShield as requested by DN. This was subsequently provided.
• Mrs M used to sleep in her chair most nights and refused to use the bed which did not help her skin integrity. She was visited by the GP, District Nurses and the Physiotherapist who all told her that this was causing her skin problems.
41. The care provider told me the care records show that:
• Mrs M suffered with a sore groin area intermittently.
• The GP was aware of this and prescribed creams.
• The area was monitored by care staff at each intervention, who used the cream as required and as per the GP’s instructions.
• Carer workers provided personal care to Mrs M throughout the day on a regular basis.
42. I reviewed the care home’s records, which showed that:
• Mrs M received regular personal care throughout the day.
• Her groin was treated for a week with a cream in December 2018.
• 28 February 2019 care plan review: Cream being applied to groin and coccyx area. Mrs M had a treatment with cream for a week at the end of which it said: ‘area healed’.
• 6 March 2019: The GP prescribed a cream as requested by the district nurse.
• 30 May 2019 care plan review: Body map reviewed. No new sore areas this week, existing ones being treated.
• In July 2019, during the week before Mrs M’s hospital admission: cream was applied every day.
• There were also creams that could only be applied by the district nurse.
43. The care provider told me the home did not complete a skin integrity care plan. However daily logs evidence care workers feedback on the condition of Mrs M’s skin during personal care provision.
44. Care records show the home would regularly inform and involve health professionals when things were noticed by staff and health professionals were regularly involved throughout.

Analysis

45. The care home should have completed a skin integrity care plan for its residents, to ensure staff had a central up to date record to refer to with regards to the management of (risk associated with) a resident’s skin condition(s). The fact that Mrs M did not have a care plan for this, even though her skin was at risk, is not in line with Regulation 12 of the Health and Social Care Act.
46. The records showed that Mrs M received regular personal care, but she had redness around her groin area. This was (at least) partly due to her decision to sleep in her chair, rather than her bed. The GP and district nurses were involved in Mrs M’s (skin) care and staff applied creams, which were to be applied on an ‘if and when needed’ basis.
47. As such, other than the lack of a care plan, I found there was no evidence to conclude there was fault in the management of Mrs M’s groin area.

The complaint about washing Mrs M’s hands and nails:

48. Mrs C says that care home staff regularly failed to clean her mother’s hands and nails. As a result, family would often find that her hands and nails were dirty, which family members subsequently had to clean.
49. The care provider told me that:
• Mrs M received full support with personal care each morning and evening. Care staff would also support Mrs M throughout the day with toileting needs and additional personal care needs as required. This would include support a full body wash including hands and nails as well as needed personal care during the day.
• Staff said Mrs M spent all her time in her room and would at times go to the toilet without support from staff. On those occasions, she would struggle to maintain her own personal hygiene so it is possible at times, depending on when staff were called to / attended that her hands would possibly need cleaning.
50. Mrs M says this is incorrect, because her mother’s mobility had deteriorated considerably towards the last few months, and she was therefore unable to use the toilet without help anymore. As such, a care worker was always called to assist her. It was the care worker’s responsibility to ensure her hands and nails were clean as she was unable to complete this task without their support.
51. Mrs M’s Continence care plan said that, as of February 2019, Mrs M was continuing to manage her continence. However, as of May 2019 it said that: Mrs M continued to be supported as she would like with her continence needs.

Analysis

52. The care home’s records show that staff provided regular personal care to Mrs M throughout the day.
53. Care home staff is responsible to ensure that, when they support a resident to use the toilet, the resident’s hands are cleaned afterwards. As Mrs M’s mobility deteriorated during her stay, she received more support towards the end from staff when using the toilet. However, Mrs C says that even though staff assisted her to the toilet every time, her mother’s hands and nails were regularly unclean.
54. Care homes do not usually keep specific records about washing hands or nails. However, I have no reason to doubt, on the basis of the information provided, that there were incidents when Mrs M’s hands or nails had not been kept to a sufficiently clean standard, which is fault.

The complaint about helping Mrs M with brushing her teeth:

55. Mrs M’s pre-admission assessment form said “able to maintain oral health independently”. However, Mrs C says she was able to brush independently, but needed help with squeezing the toothpaste onto the brush and handing it to her in her chair.
56. Mrs C says the care home often failed to assist her mother with cleaning her teeth and her mother often said her teeth had not been cleaned. This was confirmed by the fact she had the same tube of toothpaste for the majority of her stay at the home.
57. The care provider told me:
• The family raised this with the home manager. Following this, the manager carried out spot observations of staff supporting Mrs M with personal care, placed a new tube of toothpaste in her room and monitored its usage. These, along with the daily records, showed that, from the moment Mrs C raised this with the home, oral care was regularly provided.
• It was difficult to evidence if this was the case prior to the observations and monitoring, due to the way care staff completed the personal care records. As such, the home also did some work with staff on how they document intervention with residents around all personal care.
58. An analysis of records show that oral care was provided am and pm at the end of Mrs M’s stay. It was not possible to determine when Mrs M raised this issue and when, as such, the improvements were made.

Analysis

59. I found Mrs M did not receive the support she needed initially around oral care. This was fault and was not in line with Regulation 9 of the Health and Social Care Act.
60. However, after the family raised this with the care home, it took appropriate actions, and the records show Mrs M received the support she needed.

The complaint about call bell responses

61. Mrs C says that staff regularly failed to respond to the call button in an appropriate manner. When visiting her mother, her mother was often upset and calling out for help because she had called for assistance using her call button but staff either ignored the alarm or only came to turn it off and left. The family regularly raised this with management.
62. The care provider told me that:
• Staff reported that Mrs M would often call for support using her call bell. Most of the time this was for support with accessing the toilet or commode. Staff reported and documented that Mrs M would sometimes use the call bell but then forget why she used it. All residents have access to call bells and all staff are aware of the importance of answering calls bells in a timely fashion. When it reviewed the records at the time, there was no evidence that staff failed to answer call bells. There is also no evidence the family ever raised this with staff, until it made an official complaint.
• The current manager regularly tests the system by setting off a call bell and timing the response time of carer workers. This will be discussed with staff if it is a cause for concern. On discussions with staff, reviews of complaints and call bell testing done by the manager, there is no evidence there is any delay in call bells being answered in timely manner.
63. A CQC inspection in October 2019 found that:
• There were enough staff to meet people's needs. Staff responded promptly to people's requests for assistance. People said there were enough staff to provide the care they needed.
• People were treated with kindness and were positive about the staff's caring attitude. Comments included, "Staff are good, I'm lucky to live here. I get on really well with all the staff" and "The staff are lovely, we have such a good laugh."
• We observed staff interacting with people in a friendly and respectful way. Staff responded promptly to requests for assistance and did not rush people.
64. A review of a sample of the daily care records from 2019 showed that staff was in general responsive to Mrs M’s needs throughout the day.

Analysis

65. Based on the information available, I have not upheld this aspect of Mrs M’s complaint.

The complaint about food preparation

66. Mrs C says the care home failed to prepare her mother’s food at mealtimes appropriately. She said that, due to severe arthritis in her hands, her mother needed her food to be cut up at mealtimes. She also needed a spoon and a fork to feed herself. Instead, her food was not cut up and she was given a fork and knife to cut it herself. As her mother did not like to make a fuss, she often struggled to eat her meals. At times, the family found that Mrs M had either not eaten or used her hands to feed herself.
67. Mrs C’s pre-admission assessment form says Mrs M needs:
• Assistance to cut up her food: meat needs to be cut up really well.
• The use of special equipment: she likes to use a spoon and a lipped plate.
68. Mrs C’s Nutrition care plan states:
• She likes to use a fork and a spoon with a lipped plate.
• Meat needs to be chopped into very small pieces.
• A list of what she likes to eat and drink.
69. The care provider has acknowledged in its letter dated 3 October 2019, that staff were not checking her care plans to identify special needs for example the special cutlery and cutting up food”.
70. The care provider told me that:
• Not all staff regularly checked people’s care plans with regards to special needs around cutlery. This may have impacted negatively on Mrs M.
• The home reminded staff, as soon as the issue was raised, about the need to regularly check resident’s needs and to check the resident is starting to eat and is managing safely and comfortably, when they deliver meals.
• It was noted that Mrs M’s family was present during meals, at times, so staff assumed the family would assist with meals. However, staff should not have assumed this and should have checked that Mrs M was able to manage her meals before leaving her.

Analysis

71. The provider acknowledged the home did not provide the specific support Mrs M needed with regards to meal preparations. Although it is mentioned in Mrs M’s care plan, there is no evidence in the records they did. This was not in line with Regulations 9 and 14 of the Health and Social Care Act.

The complaint about personalised care (banana)

72. Mrs C says the family had asked to ensure staff gave her mother a banana every morning when she wakes up with her cup of tea before breakfast, because she liked this. She said that, despite regularly reminding staff and the fact it was recorded in her care plan, the home failed to do this. In the end the family had no choice but to do it themselves.
73. The care provider told me that, on each and every occasion this was looked into, different staff members have said, independently of each other, that staff gave a banana to Mrs M every morning, as per her care plan. She often ate this immediately. It is unclear on what basis the family is making this claim, as they did not visit in the morning. If they relied on Mrs M’s recall, then this was often not very good. Both care staff and kitchen staff have independently confirmed that bananas were regularly provided as per her preference. Whenever the family asked about this, the home strengthened its processes. It did this to reassure the family, not because it was not happening. It would be the night staff who would give the banana and said she would usually eat this quite quickly. The family has not provided evidence it (regularly) raised this with the home at the time.
74. Mrs C says the family constantly raised this with the manager. It said that, as a reminder, it was even written on the whiteboard in the kitchen, but it still did not happen. As a result, the family often went to the kitchen and got this or brought in bananas themselves.

Analysis

75. Other than conflicting statements from Mrs C and the care home as to what happened, there is no evidence to enable me to come to a view whether or not the home provided a banana to Mrs M in the morning.

The complaint about missing clothes

76. Mrs C says her mother’s clothes went missing, even when they were labelled. On average they would lose at least one piece of clothing per month, at a cost of £20 on average per month. The care provider has acknowledged in its letter dated 3 October 2019, that the standards within the laundry and clothes going missing and damaged were an ongoing issue and apologised for this.
77. The care provider told me it acknowledged in its complaint response that the home had several issues with its laundry over an extended period of staff. The home would always reimburse when it received reports of missing or damaged clothes. Laundry services are now much improved, and no further complaints have been received. A few items of Mrs M were either lost or damaged and the home provided replacement/refunds when it received receipts.
78. Mrs C says the manager only offered on one occasion to reimburse the cost of damaged items.  

Analysis

79. It appears that when the family reported that items had gone missing / damaged, the home would reimburse these. As such, if the family has any evidence that more items, than the once already reimbursed, went missing or damaged, it should present them to the home.

The complaint about recording discussions / complaints / concerns

80. Mrs C says the manager failed to minute the meetings they had with the home to discuss concerns around care. She said this lack of proper record keeping in relation to complaints is fault.
81. The care provider told me that:
• There were failings on our part particularly around communication with the family and on how we documented interactions with the family and the concerns raised.
• Looking back at records and speaking with staff, it was noted the family would often speak with the home manager. These would be adhoc contacts during visits. It was not common practice to document all conversations with families. We are aware that some of the formal meetings were not documented. As the manager is no longer with us it is not possible to get any further information on this. However, the home has made it regular practice with the new manager for all interactions with families etc. to be recorded based on the type of interaction i.e. either on our caresys (care planning system) system or via a documented meeting note.
• The new manager is very proactive in documenting all concerns and complaints raised, even if they are not received formally or in writing.
• The staff in the home have also been supported and received training and supervision on how to ensure that concerns raised by families are formalised and followed up.
82. The CQC inspection report states that:
• The service has quality assurance systems in pace now, which include reviews of care records, staff files, the environment and quality satisfaction surveys.
• The management team completed observations of staff practice, including unannounced night visits. This was to assess whether staff were putting the training and guidance they had received into practice.
• The results of the quality assurance checks were used to plan improvements to the service. A senior manager visited the home regularly to assess the service being provided and ensure the improvement plan was being implemented effectively.
• Records demonstrated complaints had been investigated and action taken in response.
• The registered manager held regular meetings for people and their relatives to express their views on the service provided.

Analysis

83. The care provider acknowledged the home did not record the discussions it had with the family, and any actions agreed, as it should have. This was not in line with Regulation 17 of the Health and Social Care Act. However, it has since made improvements in this area, which were acknowledged in the latest CQC inspection report.

Agreed action

84. I recommended that, within four weeks of my decision, the care provider should:
• Provide an apology to Mrs C, in addition to £300, for the faults identified above, the distress these have caused her and the time and trouble she had to invest in pursuing a resolution to them.
• Share the lessons learned with staff in the care home.
85. The care provider has told me it has accepted my recommendations.

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Final decision

86. For reasons explained above, I found there was some fault with regards to the care provided by the home.

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Investigator's decision on behalf of the Ombudsman