Summary: Mrs C complained about several aspects of the care support her father received at the care home he was living. Mrs C said these resulted in distress to her father and herself. We found there were some shortcomings with regards to the support Mr F received. As such, the care provider has agreed to apologise to Mrs C and her father and pay Mr F £500 for any distress he experienced.

The complaint

1. The complainant, whom I shall call Mrs C, complained to us on behalf of her father, whom I shall call Mr F. Mrs C complained about the care her father received at Charlton House care home in Plymouth. She complained:
• The home did not give her father the pull ups provided by the family, to manage his incontinence. In addition, the home failed to keep the family updated about the home’s request for a continence assessment.
• Mr F had very greasy hair and looked very unkempt and distressed on 19 February 2021.
• It took three weeks, rather than the one week promised, before Mr F could move into another redecorated room. The room he moved into was unsuitable.
• The home failed to consistently ensure a staff member would be present when Mr F would call his family, to provide any support needed, even though it had agreed to do this following her request.
• The home did not respond properly to her father’s drastic weight loss.
• Mr F continued to walk around in the (worn out) clothes of other people, despite the family repeatedly mentioning this.
• Staff failed to observe and support all visitors when carrying out lateral flow tests.
• Mr F regularly had to wait 10 minutes for his call bell to be answered.
• She regularly had to wait a long time until staff would open the outside door to them.
• Staff were using the visitor’s car park, even though there was sufficient space in the staff car park.
• Staff only told them at the end of February 2021 that there is an electronic care system that family can access to remain updated about their relative’s 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))

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How I considered this complaint

4. I considered the information I received from Mrs C and the care provider. I also interviewed the manager of the care home. I shared a copy of my draft decision statement with Mrs C and the care provider, and considered any comments I received, before I made my final decision.

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What I found

Relevant legislation and guidance

5. 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:
6. 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.
7. Regulation 10 (Dignity and respect) says that a service user’s privacy should be maintained at all times, and that personal preferences and choices related to care and treatment of service users are respected by staff at all times.
8. Regulation 12 (Safe care and treatment) says, amongst others, that care providers should:
• Respond appropriately and in a timely manner to service users’ changing needs, sharing responsibility for the care and treatment with other (health) professionals when needed.
• Assess the risk of, and preventing, detecting and controlling the spread of, infections, complying with any guidance from the Department of Health.
9. Regulation 14 (Meeting nutritional and hydration needs) is about ensuring that service users receive adequate nutrition and hydration to sustain life and good health, and to mitigate the risks of malnutrition and dehydration, while they receive care and treatment.
10. Regulation 17 (Good Governance) includes a requirement to record all feedback received from service users.

The complaint about continence management

11. Mrs C said:
• Her father struggled with continence at times, more so in terms of urgency than being incontinent.
• On arrival at the home, she provided pull ups for her father to use and asked the home to notify her when it would need more. However, the home did not ask for more pull ups after December 2020, or ask to provide regular underwear instead, when his pull ups were finished.
• The pull ups were more dignifying for her father than the netted pants with pads the home gave him (‘netted pants’ are figure hugging pants to hold shaped incontinence pads securely in place).
12. The home told me that:
• Mr F became more independent while living in the home with using the bathroom. As such, instead of having to wear pads, the home gave him underwear to promote his independence and using the bathroom.
• It acknowledges that it failed to inform the family about this, for which it is sorry. Since this, the home has introduced a ‘message communication book’ to record all events or information that needs to be communicated across to family to provide them with a better understanding and ensure clear communication between the home and family.
13. The records show that staff continued to check and change Mr F’s pads during January and February 2021. This indicates that, while he was more independent with toileting, he was still using pads (with netted pants) until the latter part of his stay at the home.
14. Mrs C also complained the care home failed to keep the family updated about (the lack of progress of) the home’s request to the NHS Continence Service for an incontinence assessment. She says that when Mr F went into the home in November 2020, the home said it would put him forward for a Continence Assessment in January 2021. However, this never happened
15. The care home previously told Mrs C that it submitted a request for a continence assessment in November 2020. However, it has now acknowledged, in response to my enquiries, that it only made the referral mid-February 2021. However, Mr F’s GP subsequently said such an assessment would not be required for him.

Analysis

16. The home said it switched Mr F from pull up pants / netted pants, to underwear, when it became clear he had become more independent with toileting. It said this supported his independence and dignity. However, the records show that staff continued to check and change Mr F’s pads during January and February 2021. This indicates that, while he was perhaps more independent with toileting, the home was still using pads (with netted pants). Mr F’s family preferred Mr F to use pull up pants as this would be more dignifying, which the family said it would provide. As such, the care home should have asked the family for additional pull up pants when it ran out. The failure to do this, and discuss these issues with the family, was fault, for which it should apologise. This was not in line with regulation 10 (dignity and respect).
17. The care home was also at fault for a delay in making the referral for a continence assessment. However, Mr F’s GP subsequently said such an assessment would not be required for him. As such, the care home’s fault resulted in limited injustice to Mrs C. Nevertheless, the care provider should apologise for the delay.

The complaint about greasy hair

18. Mrs C complained that Mr F had very greasy hair and looked very unkempt when she visited him on 19 February 2021.
19. Mr F’s assessment says that, at times, he could decline all help with washing showering and dressing. As such, the care home said that Mr F may have had greasy hair on rare occasions. It said staff would always offer the correct personal care, but Mr F made it difficult for staff to provide this.
20. The care records I reviewed showed evidence of Mr F having regular showers (once every 1-3 days) up to February 2021. Staff would also regularly wash him, shave him, comb his hair, check his nails etc. However, he only had a shower four times between 1 and 19 February, including on 18 February, the day before Mrs C said his hair looked greasy. There is no evidence in the daily care records to indicate this reduction in frequency in February was due to him refusing a shower. However, staff continued to regularly provide him with other personal care, including normal wash(es) during February.
21. When Mrs C mentioned Mr F’s greasy hair, staff immediately gave him a shower, washed his hair and recorded that he will need to have a shower every day from now on. Mr F moved to another home in March 2021.

Analysis:

22. Although Mr F only had four showers between 1 and 19 February 2021, which was insufficient, the records show the care home provided overall an appropriate level of personal care support to Mr F. This was in line with regulation 9 (Person-centred care).

The complaint about Mr F’s unsuitable room:

23. Mrs C complained that:
• When the family applied for a place at the home, the home advised them Mr F would have a temporary room for a week until his allocated room would be fully decorated. However, it took three weeks.
• The redecorated room he moved into was unsuitable. There was only a “bi-fold/sliding door” between her father’s room and the adjoining room. There was a slight gap around the entire dividing door frame, and this allowed noise and light to enter his room. She said those conversations and noises were very confusing for a person with dementia, such as Mr F. The family raised this as an issue and suggested that a partition or stud wall could be put up to afford better soundproofing and privacy. The management denied ever having been told of this request and replied this had not been an issue for the previous resident who had occupied the room for several years.
24. In response, the care provider said:
• There was unfortunately a delay with the room being ready within a week. Due to Covid-19 restrictions, there was a delay in finding and getting materials to undertake the refurbishment of the room, as well as external contractors. As such, three weeks was not excessive.
• While recognising the impact the noises were having on Mr F, the room was built and prepared to an appropriate standard. It moved Mr F to another room after the family expressed its concerns.

Analysis

25. I found that three weeks was not an unreasonable delay, in light of the circumstances described.
26. I am unable to determine to what extent it was possible to overhear conversations in/from the redecorated room. If this was the case, as claimed by Mrs C, this would not have been in line with regulation 10 (Dignity and respect), which says a service user’s privacy should be maintained at all times.
27. When the family raised concerns about the room, the care provider took the correct action and offered to move Mr F to an alternative room.

The complaint about support during phone calls

28. Mrs C said her father would often become emotional when making a phone call with a family member. As such, she asked the home on 20 February 2021 to have a staff member with him during phone calls. She said the home promised to do this, but she said there were still a couple of occasions when no staff member was there to support him. Mrs C mentioned one occasion (24 February) when this did not happen.
29. Mr F’s care plan said that: my wife and daughters will call me on the phone most days and this appears to impact my well-being and can caused me a lot of distress. At this time, I will need a lot of support from the staff when I do not understand why I can’t go home with my wife or go out when I want.
30. The home said it ensured after 20 February 2021, that a member of staff would be with Mr F, or close by him, when he would be speaking to family on the telephone, to allow for staff intervention should he become distressed.
31. It is difficult to determine from the records if a staff member was actually nearby every time Mr F would call his family. However, in addition to Mrs C’s statement, I have seen a record for instance on 26 and 28 February that indicates this may not have been the case every time.

Analysis

32. The care home said it would ensure that a staff member would always be nearby when Mr F would call his family. This is in line with regulation 9 (Person-centred care) which says each service user should receive care that is personalised specifically for them, that meets their needs and reflects their preferences. However, the care home was subsequently unable to provide that support on a few occasions, for which it should apologise.

The care home’s response to Mr F’s weight loss

33. Mrs C said her father had significant weight loss following his arrival at the home; he lost 11 kilograms since he arrived at the end of November 2020. However, she said: the care home failed to notice this on time, failed to investigate why this was happening and failed to consider a referral to a health professional, in a timely manner. If it had done so, it would have been able to allocate a staff member sooner to support him during mealtimes, which would have prevented further weight loss at an earlier stage.
34. According to the records, Mr F was 97 kilograms when he arrived at the home, which meant he was overweight. In early January 2021 Mr F was 90 kilograms, which meant he had lost 7 kilogram in less than two months. However, there is no evidence in the records that shows the care home spotted there had been a significant weight loss over a short time and/or looked into this, at that particular time.
35. Mrs C called the care home on 18 January 2021 and said she felt her father was losing weight. The records state the home assured her it was monitoring everything very closely. However, there is no evidence in the records that shows the home carried out any specific action in response to Mr F’s weight loss or Mrs C’s concern at that time.
36. On 10 February, Mr F’s weight was measured as 85 kilograms. This meant he had lost 12 kilograms since he went into the care home, including another 5 kilograms in the last month. The care home record states “Send weights to GP for review”.
37. The home did eventually speak to a health professional (paramedic) on 18 February 2021 about Mr F’s weight loss and his MUST (Malnutrition Universal Screening Tool) risk score of 2 (high risk; significant unplanned weight loss in previous 3-6 months). This score usually requires the involvement of a dietician. The care home sent all weight measurements to the paramedic and contacted the GP to discuss Mr F’s weight loss.
38. The home manager also alerted staff on 19 February 2021 to make sure they would all: record Mr F’s food and fluid intake, encourage him to eat his meals, and offer sweet snacks in between main meals. Staff were also told to ensure Mr F would get a cooked breakfast every morning and would be offered a milkshake in the afternoon to boost calories intake.
39. The paramedic visited Mr F at the home on 21 February 2021 and advised that Mr F should aim to maintain his weight at/above 80kg, until he could be reviewed by a dietitian. He said that a healthy weight range for Mr F would be between 60 to 80kg (to maintain a BMI of 18.5 to 24.9).
40. Despite the support of health professionals, and staff spending more time to encourage Mr F to eat and provide him with a high calorie diet and snacks, Mr F lost a further two kilograms until he left the home two weeks later.
41. The care provider acknowledged to the Council at the time, that: having looked at the MUST assessment and his weight measurements since Mr F came to the home, it clearly shows there were some irregularities with his weight measurements, and how staff have measured his weight. As such, it said it would remind, retrain and monitor staff in weighing individuals, completing MUST assessments, and reporting concerns to external medical professionals.
42. The care provider told me it now carries out weekly weighs on all residents in the home so weight loss or gain will be promptly alerted to the GP for advice and treatment if required and communicated to family.

Analysis

43. There was a delay by the care home in recognising that Mr F’s weight loss since his admission was an issue it needed to look into. There were missed opportunities to do this on 8 and 18 January 2021. This is fault and not in line with regulation 12 (Safe care and treatment) which says care providers should respond in a timely manner to changing circumstances and involving other (heath) professionals promptly when needed. It eventually took the correct steps mid-February 2021. At this point in time, Mr F still had a healthy weight.
44. It is difficult to determine to what extent the above fault resulted in a significant injustice, because even once health professionals became involved, and the home was taking additional actions, Mr F still continued to lose weight. As such, I am unable to conclude that an earlier intervention would have made a significant difference.

The complaint about Mr F’s clothes

45. Mrs C complained her father walked around in the (worn out) clothes of other people, despite the family repeatedly mentioning this and having labelled all his clothes. Mrs C said she saw her father on 19 February 2021 in someone else’s jumper again and checked his wardrobe. She found 6 to 8 jumpers, socks and trousers that were not his.
46. Furthermore, Mrs C said that:
• The care home’s excuse (he goes into rooms and put their clothes on) cannot be correct as he needed help with putting clothes on by a staff member.
• When these incidents happened, the staff failed to notice this and take action to change his clothes
47. The home said this did not happen as regularly as suggested by the family. However, it had a meeting with the housekeeping team following Mrs C’s complaint. It also told staff on 19 February 2021 to make sure that Mr F was dressed in his own clothes, which had all been labelled by his daughters.

Analysis

48. The home has acknowledged there were occasions on which Mr F would be wearing (worn out) clothes that belonged to other residents. This was not in line with regulation 10 (Dignity and respect).
49. Furthermore, Mrs C found clothes in her father’s wardrobe that did not belong to him. This should not happen, which is fault.

The complaint about lateral flow tests

50. Mrs C complained that staff failed to observe and support all visitors when carrying out lateral flow tests, which resulted in an increased chance the test would not be accurate.
51. When the Council looked into this, as part of a safeguarding investigation, the records state the home manager admitted that staff had been unsure on how to conduct the test on families and visitors, as the staff only had limited training on this.
52. The care home told me this had subsequently been addressed by placing guidance in the main entrance for visitors to follow, who would be supervised by a designated trained staff member.

Analysis

53. The care home manager acknowledged to the Council that it initially did not have an appropriate process in place, supported by trained staff, which is fault and not in line with regulation 12 (Safe care and treatment) which says care providers should prevent the spread of infections by complying with any guidance from the Department of Health.
54. The care provider has since taken the correct steps to address this. The above will have resulted in some distress to Mrs C.

The complaint about having to wait a long time to enter the home

55. Mrs C said she and her elderly mother regularly (approximately 20 times) had to wait for 10-15 minutes until staff opened the outside door and let her in. She said this was very annoying and uncomfortable having to wait so long in the cold and she regularly raised this as an issue.
56. In response, the home has acknowledged to me that this was a problem, and it is very sorry for the distress this caused. It says that, as a result, it has installed an intercom system and ensured that a staff member is always located close to the door to respond quickly when the doorbell rings.

Analysis

57. While the care home acknowledged this had been a problem, which was fault, it has since taken the correct steps to address this. The above will have resulted in some distress to Mrs C.

The complaint about the slow response to call bells

58. Mrs C said her father often said he had to wait 10 minutes for his call bell to be answered. The family has also witnessed this during visits.
59. In response, the home said it was sorry for any delay in responding to a call bell, when it activates. It explained all staff are aware that call bells must be answered swiftly and promptly and the home trains staff during their initial induction on how to effectively answer the call bell and the importance of this.
60. The home told me:
• Its system does not collect records that show how long it takes to respond to call bells.
• Both the registered manager and care manager are based on the care floor, so they are near the residents and can monitor call bells and care being given to the residents.
61. A CQC inspection report from February 2020 said that:
• People told us they felt safe living in Charlton House. They said, "The staff are wonderful they come when you need them" and, "I have my call bell so can get the carers to my room to help me."
• A professional said: "There always appears enough staff for the amount of residents."

Analysis

62. Based on the limited information available, it is not possible to determine to what extent this was an issue for Mr F. However, the CQC inspection found that residents were happy with the way staff responded to call bell alerts.
63. The care home’s call bell system is unable to record how quickly staff respond to call bells during the day, or at night. It would be good practice for the home to look into setting up a system that can do this.

The complaint about staff using the car park

64. Mrs C complained that staff were using the visitor’s car park, even though there was sufficient space in the staff car park.
65. In response, the home said:
• The care home has two car parks: one for family members and one for family and ambulance service. During the lockdown, the staff was allowed to use both car parks if parking became difficult.
• The visitors care park is always available during the day to accommodate visits in the home.
• There are times when the visitor’s car park has to be used as an overflow car park for staff.

Analysis

66. The home said the increased use by staff of the visitor car park was due to staff being more reliant on traveling by car (than by public transport) during lockdown. As such, there is no fault the home prioritised staff being able to get to the home and use the visitor’s car park when needed.

The complaint about the delay in informing Mrs C about its electronic care system

67. Mrs C says the home only told them at the end of February 2021 that there is an electronic care system that family can access to remain updated about their relative’s care.
68. In response, the care home said its electronic system is a relatively new practice. Not all families are interested in this. The home needs to have a measured approach, and if requested it certainly is something we can offer.

Analysis

69. The care home could have told Mrs C at an earlier stage that there was an electronic care system that it could allow a family to have access to. However, it is not made accessible as standard to all families for various reasons, such as patient data confidentiality. It would be good practice for the care home to develop a protocol / process for determining when and how it makes this accessible to families.

The way the home records concerns

70. Mrs C says that on numerous occasions members of the family have spoken with members of the care staff about issues related to his care. The family did this by telephone, face to face and via email. However, the care home manager said on 20 February 2021 that these had not been brought to her attention.
71. The care home says that, in terms of recording concerns raised by family members:
• The procedures for staff to record information from family are via the person-centred software.
• The home has now implemented a message system to help with better and clear communication with the family of residents. Any concerns will be recorded in writing and provided to the home manager, so there will be a paper trail.
• There is an office manager who records all telephone conservation and messages from family members and outside professionals.
• This system works really well and since in place we have had great feedback from family and outside professionals. All concerns are promptly dealt with by the managers to ensure the safety of all our residents

Analysis

72. I have no reason to doubt Mrs C’s statement that some of the issues she raised were not properly recorded and / or disseminated to the manager and/or other staff. This is not in line with regulation 17 (Good Governance) which includes a requirement to record all feedback received from service users.
73. The care home has explained how it has improved the way it records and passes on issues or concerns expressed by family members.

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Agreed action

74. I recommended that, within four weeks of my decision, the care provider:
• Provides an apology to Mrs C and her father for the faults identified above and any distress these may have caused them as a result.
• Pay Mr F £500 for any distress he experienced.

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Final decision

75. For reasons explained above, I found there was some fault by the care provider.
76. I am satisfied with the actions the care provider will carry out to remedy this and have therefore decided to complete my investigation and close the case.
77. In line with our Memorandum of Understanding, I have shared the decision with the CQC.

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Investigator's decision on behalf of the Ombudsman