• The complaint
• The Ombudsman’s role and powers
• How I considered this complaint
• What I found
• Final decision

The Ombudsman's final decision:

Summary: Mr C complained about the standard of care his wife received while in the Old Rectory Care Home. We did not find fault with the Care Provider’s actions.

The complaint

1. Mr C complained about the standard of care given to his late wife, Mrs C, while in the Old Rectory Care Home (the Home) managed by Chantry Retirement Homes Ltd (the Care Provider). He said the Home failed to provide the service agreed and his wife deteriorated rapidly due to its neglect and poor care. He also complained his daughter was harassed by the manager and the owner. The whole family was affected by the stress of the situation.

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The Ombudsman’s role and powers

1. 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. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
2. 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

1. I have considered the complaint and the documents provided by the complainant, made enquiries of the Care Provider and considered the comments and documents it provided. Mr C 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

1. Mrs C moved into the Old Rectory care home (the Home) in July 2020. She had a number of health conditions and required help with all personal care tasks. Prior to this she had been living at home with her husband Mr C with carers and her husband looking after her.
2. The Home’s care records show that it carried out a comprehensive assessment of Mrs C’s care needs and preferences. It noted she had poor mobility and hearing, was incontinent and a little confused at times, needed her food cut up and was afraid of falling. The Home also noted her skin was very thin and prone to tearing (she used a pressure cushion and liked to walk around regularly to relieve the pressure), her communication was good, and she liked having a bath. She said she preferred to have meals in her bedroom, but staff would always ask if she wished to use the dining room. The Home completed a body map showing some bruises and swellings. The Home initially assessed she needed one carer to assist her.
3. When she first arrived at the Home, she was required to self-isolate for two weeks due to the COVID19 pandemic.
4. The medication charts show that the Home gave her medication as prescribed. There were occasions when Mrs C refused to take it. As she had capacity the Home could not force her to take it.
5. The daily care records show throughout her stay Mrs C was generally in a good mood, ate and drank well and spoke to family members by telephone as well as through the window. On 5 August 2020 she asked the staff when isolation was finishing so she could have a bath. Staff told her isolation was ending in two days.
6. Her family visited her on the day isolation ended and she saw them through the lounge window downstairs. These visits continued on a regular basis, sometimes in person. She had a bath several days after isolation ended, and then on a weekly basis. She regularly went downstairs into the lounge and dining room.
7. The district nurse visited on 25 August 2020 regarding a skin tear the Home had found that morning. The Home had already informed the family. On 26 August 2020 Mrs C banged her leg on her wheelchair causing another skin tear. The Home informed the family and asked the district nurse to visit. The Home decided that Ms C now needed two carers for support as her skin was so fragile.
8. On 27 August 2020 the Home noticed a new skin tear on her leg. The Home completed an incident form and informed the district nurse who visited, checked the wounds and changed the dressings. The Home asked the district nurse for advice on how to prevent further skin tears. She suggested pyjama trousers and a pillow between her legs at night. She said the tears could be caused by anything, even Mrs C just rubbing her legs together.
9. On 28 August 2020 the family raised a concern about the number of skin tears, saying that Mrs C had four plasters when they had only been informed about three. The Home confirmed there were only three on Mrs C’s left leg and invited the family to visit so they could see for themselves. The Home felt the family member was rude and aggressive to the Home’s staff and asked them to apologise. They declined to do so. The family visited the Home and saw there were only three plasters on Mrs C’s leg. They apologised for the telephone call.
10. Later that day when Mrs C was getting ready for bed she asked a carer to help her hang up the telephone (she had been talking to her daughter). Once she was in bed she asked a carer to put her daughter’s telephone number into the telephone as she was struggling to dial it.
11. The district nurse visited again on 29 August 2020 to check the skin tears.
12. On the evening of 30 August 2020, the Home noticed Mrs C was lethargic and tired. At the shift handover in the morning the night staff suggested a urine test. The day staff were also concerned when they tried to help Mrs C get up, that she was struggling to stand, had a puffy eye and was quiet. The staff consulted the senior carer who decided she would call 111 for advice. While doing this, a member of the family telephoned and said they were not happy with the care the home was providing, so would be taking her home. The 111 service sent the paramedics to see Mrs C. While they were attending to Mrs C another family member arrived at the Home in a distressed state asking to see Mrs C. The paramedics took Mrs C to hospital.
13. The family found Mrs C a place at a different care home where she stayed for a month before she died.
14. Mr C complained to the Home about the care she received. He said she was in a terrible state when she went into hospital and the ambulance staff had made a safeguarding referral. He said she told him she was left for hours on end alone, her painkillers were removed and her arthritis medication was terminated. He said she was not able to have a bath or shower or wash her hair for a whole month, she sustained three skin tears, numerous bruises and her mobility deteriorated. He also said his daughter was very upset by a telephone call with the manager and that she had been listening to a private call. He said the staff at the Home should be apologising to them.
15. On 3 September 2020 the Council contacted the Home to say it had received a safeguarding referral regarding Mrs C. Concerns had been raised about unexplained bruising and skin tears. The Council said:

From information gathered during safeguarding enquiry no evidence has been found that staff failed in their duty of care or that [Mrs C] experienced neglect within the care setting. [Mrs C] had bruising on her arms/legs on admission to The Old Rectory which you confirmed had been body mapped. Health professionals were involved confirming that from their involvement they had no concerns re: the care [Mrs C] had received and that they were kept informed re: her skin condition with staff calling for advice when needed. CQC received a report detailing The Old Rectory had stopped [Mrs C’s] medication. You confirmed medication would not be stopped without input/guidance from GP or Advanced Nurse Practitioner. I queried this with the [District Nurses] who advised it was documented that [Mrs C] was refusing medication at times and as she is deemed to have capacity she could not be forced to take meds. You advised you had placed [Mrs C] on 2:1 support to enable staff transfer/care for her appropriately and reduce the risk of bruising/skin tear due to her frailty.

1. The Council said it had informed Mrs C’s daughter and the CQC of its finding.
2. The Home replied to Mr C’s complaint on 29 September 2020. It said that:
   • Mrs C had bruises and swellings when she arrived at the Home and these had been documented on the body map.
   • The medication charts showed that all her medication was administered on time apart from the painkillers which were to be taken when Mrs C requested them.
   • Mrs C regularly went into the lounge and was settling well. She was rarely left alone unless she wished to be in her bedroom and was then checked regularly.
   • One skin tear was caused with the wheelchair and the family had been informed.
   • Some family members had been abrupt and impolite to staff at the Home.
   • The Home manager had never listened to private calls.
   • The ambulance staff were right to raise the safeguarding concerns but the Council had closed the investigation as it was satisfied with the care given. The Home also said a full safeguarding report had been sent to the Mr C’s daughter.
3. The Home said the concerns were unfounded, the staff were all professionals and it wanted the family to apologise for suggesting otherwise.
4. Mr C then complained to us.

Analysis

1. It must have been distressing for the family to witness Mrs C’s deterioration at the end of August necessitating a trip to hospital. However, I cannot find evidence of fault in the Home’s actions to substantiate the allegation that this was due to poor care.
2. The Home’s records show a thorough assessment was done when Mrs C entered the Home, including body-mapping, risk assessments of falling, skin condition and continence along with details of Mrs C’s preference in terms of eating, drinking, washing and daily living. The daily care records provide further detail to support the view that Mrs C was generally happy and content, eating drinking and sleeping well. She also went downstairs regularly to the communal areas.
3. She had at least four baths during her stay but there was a delay of nearly three weeks due to Mrs C having to self-isolate. This may also explain why Mrs C said she was left alone and did not see anyone.
4. The records show that Mrs C’s bruises were there when she arrived, that the skin tears were noticed promptly, the family was informed and the district nurses called. Staff also asked for advice on how to prevent these recurring and implemented 2:1 care to further reduce the risk. There is no evidence that Mrs C’s medication was stopped or missed. The Council’s safeguarding team found no evidence of neglect or poor care.
5. Mrs C first showed signs of illness on the evening of 30 August 2020 but slept well. The Home sought medical advice and assistance the next morning leading to her admission to hospital.
6. In terms of the allegations of rudeness, it is clear the family were anxious and distressed when skin tears were discovered and when Mrs C’s health deteriorated, which may have affected the way they spoke to the Home’s staff. The statements from the staff indicate that they tried to respond professionally and provide relevant information in response to the concerns. They explained what had happened regarding the telephone call on 28 August 2020 and clarified that Mrs C had three skin tears on her left leg. I understand the family did not perceive the interactions in this way, but there is no evidence to support the claim that the staff were rude.

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Final decision

1. I have completed my investigation into this complaint as I am unable to find fault in the actions of the Care Provider towards Mrs C.

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Investigator's decision on behalf of the Ombudsman

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