The Ombudsman's final decision:
Summary: There is no evidence of proper oral care for Mr X. Mr X incurred dental fees as a consequence which the care provider has reimbursed. There was poor maintenance of some fluid and hygiene records although their absence is mitigated by the detail in the daily records. Beyond the failure to provide the proper standard of oral hygiene, which the care provider has already remedied, there is no evidence the care provider’s actions caused injustice to Mr X.
- Mrs A (as I shall call the complainant) complains about the poor care and treatment of her father in Ferndown Manor; in particular she complains about his poor hygiene and oral hygiene, failure to provide sufficient fluids, and failure to ensure Mr X was regularly dressed and sitting with other residents.
The Ombudsman’s role and powers
- 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)
How I considered this complaint
- I considered the information provided by the care provider and by Ms A. We spoke to Ms A. Both Ms A and the care provider had the opportunity to comment on an earlier draft of this statement and I took their comments into consideration before I reached a final decision.
- Under our information sharing agreement, we will share this decision with the Care Quality Commission.
What I found
Relevant law and guidance
- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
- Regulation 9 says the care and treatment of service users must be appropriate, meet their needs, and reflect their preferences.
- Regulation 10 says service users must be treated with dignity and respect.
- Regulation 14 says the nutritional and hydration needs of service users must be met.
- Regulation 17 says care provider must maintain an accurate, contemporaneous and complete record in respect of each service user.
- Mr X became resident in Ferndown Manor in April 2017. His solicitor held a lasting power of attorney (POA) for him.
- As well as some physical illnesses Mr X had Alzheimer’s disease and was no longer able to live at home. His care plan said he ‘likes his privacy and likes to spend time in his room’. It described him as having his “own teeth with a top plate with one tooth” and requiring assistance to clean his teeth and denture. The care plan also said he needed to be offered drinks regularly throughout the day. Care plans were reviewed on a monthly basis and later care plans referred to the need to keep food and fluid charts, and to offer fortified smoothie drinks, in view of Mr X’s weight loss.
- Daily notes of Mr X’s care show that as time went on he began to stay in his room more often, although the evidence shows that staff encouraged him to join in activities (“(Mr X) was offered to go to the activities this afternoon but declined, preferring to stay in his room”). He continued to eat most meals in the dining room, however (“he came out of his room for supper and ate with the other residents”).
- The daily care notes also state frequently that staff offered Mr X fluids (“fluids were encouraged’, ‘a new jug of water was placed in his room’) and completed food and fluid charts. Mrs A says this is not correct. She says staff would offer her father a cup of tea, for example, but if it was refused they would either throw it away or offer it to visitors. She says paramedics who visited him on one occasion said he was dehydrated.
- In April 2021 Mr X had an unwitnessed fall. The care notes say he was found on the floor with a cut to the left side of his head. He was seen by the nurse and checked over completely but there was no apparent other injury. It was agreed the visiting GP would assess him the following day. In the early hours of the following morning Mr X complained about pain in his left hip and so the care home staff called paramedics. Mr X was taken to hospital. He was uninjured but did not return to Ferndown as Mrs A found him another care home. Mrs A says the hospital discharge nurse was unhappy about her father being discharged back to Ferndown.
- In July 2021 Mrs A complained to the care provider. She said her father had been very thin and dirty when he was admitted to hospital. She said his oral hygiene had been very poor and he had incurred significant dental fees as a result of the neglect of his teeth. She also complained about poor personal care and failure to maintain his hydration which she said had contributed to the incidence of his falls.
- The care provider’s operations support manager responded. She said she knew the home manager had discussed Mrs A’s concerns with her when she had raised them during her father’s stay at the home. She said it was recorded that Mr X preferred not to join in group activities. She said a review of his case records showed that personal care and oral hygiene had been undertaken as part of Mr X’s care plan. She said as a goodwill gesture the care provider would reimburse the dental fees of £788.
- Mrs A remained very unhappy. She complained again. She said her father’s dentures had been encrusted with hardened food when he went into hospital. She said he had not been given enough to drink while he was in the care home and care staff had told her they didn’t have time to sit with him while he drank. She said his personal hygiene had been neglected.
- The care provider’s regional manager replied. He said the investigation of her complaint had not been able to substantiate the oral care which had been given and so he supported the decision to reimburse the dental fees. He said new oral health training had been given to staff. He also said “following a safeguarding investigation carried out by the local authority in response to your concerns a recommendation was made that record keeping regarding care planning and daily records should be more concise and specific in regard to personal care given and this has been actioned. The Safeguarding investigation has now been closed without further recommendation”.
- Mrs A complained to the Ombudsman. She said her father had been very thin and unkempt when he was admitted to hospital. She said the home should have encouraged him to leave his room more often for activities rather than rely on his word that he would rather stay in his room. She says she wanted to move him from Ferndown sooner but his solicitor (who has the power of attorney for Mr X’s finances and health and welfare) would not agree to move him until after his hospital admission.
- The care provider says the “daily notes show that fluid charts were in place and detailed information in relation to food and fluid intake” but acknowledges they are unable to find the copies of the food and fluid charts. They say they cannot trace records of an incident Mrs A mentions when paramedics were called to her father because he was dehydrated.
- The care provider’s notes show that between November 2020 and May 2021 there were only 12 occasions on which oral care was recorded as having been given. The most recent oral hygiene assessment in March 2021 stated “Food particles, tartar, plaque in 1-2 areas of the mouth, teeth or dentures, halitosis (bad breath)”. The care provider says this “indicated the need to see a dentist” and says the previous three months assessments were the same. The care provider does not say why no arrangement was made for Mr X to see a dentist in view of the outcome of the assessments.
- The care provider also says, “Safeguarding and the LA were fully aware of concerns that were raised and these were all dealt with and closed by safe guarding with no further actions from these. The POA was also made aware of this and no further concerns have been raised to us through the POA.”
- The care provider acknowledges record-keeping was not comprehensive at the time and says that has now been addressed in the home.
- The daily care notes evidence an appropriate standard of personal care was given with the exception of oral care, for which the care provider has minimal records. The oral hygiene assessment suggest this care was lacking. The care provider has reimbursed the dental fees incurred but in my view that does not go far enough to remedy the injustice of the consequences of poor mouth care to Mr X.
- Although the daily care records frequently mention the encouragement of fluids, the care provider cannot trace the charts. That is not in keeping with the requirements of regulation 17. However, I have not seen any evidence to say Mr X suffered from dehydration, nor was safeguarding action taken by the local council in this respect.
- Mrs A says the care provider at the home where Mr X now lives makes sure he regularly mixes with other residents. Evidence from Ferndown notes Mr X regularly ate his meals with other residents but preferred to spend time in his own room, even when encouraged to join in activities. As his care plan specifically noted he “liked his privacy” I am not minded to consider it as fault on the part of the care provider that they respected his wishes not to mix regularly with other residents.
- The care provider has already reimbursed the dental fees but will now also, within one month of my final decision, offer the sum of £500 to Mr X in recognition of the injustice that continued poor oral care caused to him while resident in the home;
- The care provider will ensure it maintains “accurate, contemporaneous and complete records” in line with the regulations.
- I find that the actions of the care provider caused injustice to Mr X, which completion of the recommendation in paragraph 26 will remedy. I have completed the investigation on that basis.
Investigator's decision on behalf of the Ombudsman