Summary: Mrs X complained on behalf of Mrs Y, about the care she received at Tallington Care Home (the Care Provider). She says Mrs Y was put at risk and when family raised concerns, staff were aggressive. We found the Care Provider did cause injustice to Mrs Y and Mrs X because staff did not always follow care plans. We recommended the Care Provider apologise and take action to prevent similar problems in future.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complained that during her mother, Mrs Y’s, short stay at Tallington Care Home, the Care Provider:
• Left medication in Mrs Y’s room and did not ensure it was administered correctly.
• At times, left Mrs Y alone at lunchtime although her care plan mentioned a risk of choking.
• Left Mrs Y in soiled pads and did not increase checks as agreed.
• Did not explain bruises and abrasions and did not record them until Ms X raised them.
• Allowed male staff to toilet Mrs Y although her care plan specified that it should only be female staff.
• Did not give due care and attention to dressing Mrs Y.
• Did not replace hearing aid batteries although her care plan specified these should be changed every Friday.
• Sat Mrs Y in the doorway of the café so staff could see her but other diners would not be upset when she removed her dentures.
• Became aggressive when questioned about these issues.
2. Mrs X also complained that Mrs Y had lost 9lbs in weight during her stay at Tallington Care Home and concerns were raised about this during a hospital appointment. She also says the Care Provider did not investigate her complaint properly. Mrs Y was put at risk and Mrs X was made to feel as if she had no right to raise concerns. She says the family felt fooled by the home’s nice appearance and would like staff to be accountable for their actions.

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The Ombudsman’s role and powers

3. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word ‘fault’ to refer to these. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
4. If we are satisfied with a council’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)
5. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended). We consider Mrs X to be a suitable person to complain on Mrs Y’s behalf.

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How I considered this complaint

6. I considered information from the Complainant and from the Council.
7. I sent both parties a copy of my draft decision for comment and took account of the comments I received in response.

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What I found

Background

8. 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) has issued guidance on how to meet the fundamental standards below which care must never fall.

The Care Quality Commission

9. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
10. Regulation 9 is about personalised care. The CQC’s guidance on the regulations says:
• “Providers must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate, meets their needs and reflects their personal preferences, whatever they might be”.
11. Regulation 10 is about dignity and respect. The CQC’s guidance on this regulation says: “When people receive care and treatment, all staff must treat them with dignity and respect at all times. This includes staff treating them in a caring and compassionate way.”.
12. Regulation 12 is about safe care and treatment. The guidance says:
• “Providers must do all that is reasonably practicable to mitigate risks”.
• “Staff must follow plans and pathways”.
13. Regulation 17 is about good governance. 17(2)(c) says care providers should “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided”.

What happened

14. Mrs Y moved to Tallington Lodge for respite care after a hospital stay in mid May 2021. She stayed for just over one month. Mrs Y often had more than one visit from family members each day. Mrs X visited often and kept a careful check on the care Mrs Y received.
15. Mrs X became concerned about various issues which she complained about to staff and in mid June contacted Head Office to speak to senior management. The issues raised in Mrs X’s complaints to us are listed above in paragraph 1.

Medication left in Mrs Y’s room

16. Mrs X says she and her brother, Mr Z, found pills in Mrs Y’s rooms on three occasions despite having raised it with the manager the first time. Mrs Y’s care plan for “Medication usage and Risk” says that Mrs Y has stored medication in her mouth and therefore the senior care worker must ensure that she has “totally swallowed” her medication. The Care Provider said it investigated and staff denied leaving medication. It carried out two random checks and found no evidence of this happening. It did not uphold her complaint about this.

Weight loss

17. Mrs X says Mrs Y lost 9lb weight while she was at Tallington Lodge. Mrs Y’s care plan for “Food, Nutrition and Meal Times” says: “I have lost weight recently & need weighing regularly.”. Also, “I need to be weighed monthly”, and “I have a long history of weight loss”. The Care Provider has sent records showing weight recording on eight occasions over the five weeks with appropriate risk assessments.

Mrs Y left in soiled pads and checks not increased as agreed

18. On two occasions, Mrs X found Mrs Y wearing a soiled continence pad. The Care Provider said it would check Mrs Y’s toileting needs two hourly.
19. Mrs Y’s care plan for continence needs notes, “I do require assistance when going to the toilet & my pad checking every 2 hours, however at times, I may refuse.”. The care plan for “Urinary Tract Infection” says “Encourage [Mrs Y] to use the toilet every 2 hours as planned.”. This equates to about 8 checks per day.
20. The “comfort round” record shows regular checks daily except for one day. On four days there were only one or two checks and on three days there were eight checks. Most days showed four or more checks. There are also records in the daily notes which show regular records of assistance to the toilet, prompting to use the toilet or pad checks and changes. There are no entries here on several days. Most days have one or two records though some of these make general comments like “toilet throughout the day”, or “is encouraged to use the toilet 2 hourly to manage her incontinence.”. There are two days when staff noted more than two continence checks. One of these days was when the GP visited following Mrs X’s concerns about Mrs Y being unwell which had three entries. The other day had four entries, one noting “very strong urine”. Staff alerted the GP and Mrs Y was found to have a urinary tract infection. Mrs X says the Manager initially offered the two hourly checks then told her they could not continue with them as there were not enough staff.
21. The Care Provider’s investigation did not reference the care plan and said Mrs Y was supported regularly with her continence. It did not uphold the complaint.
22. I should note that even if Mrs Y was checked two hourly, this would not necessarily mean her pad would not be soiled at the time of a visit from Mrs X.

No explanation or records for bruises and abrasions

23. Mrs Y’s care plan for “Skin Assessment and Risk” says: “My skin bruises easily”, also “[I] tend to scratch at my arms.”. The care plan reviews note that the scratch on Mrs Y’s arm was likely to be self inflicted. The records show one entry prior to these events and one after.
24. Mrs X and Mrs Q had noticed a couple of residents with black eyes and bruises to their faces. They asked staff how this had happened as they were interested in the Care Provider’s policy about falls. The Manager told them the residents had skin blemishes removed and could not discuss it further. During Mrs Y’s stay, she had bruises on her legs and wrist. Mrs X’s sister, Ms Q, noticed an abrasion to Mrs Y’s arm and questioned Mrs Y about how it happened. She asked if she had knocked it or fallen and Mrs Y said no. Then Ms Q asked whether it was a lady or a man to which Mrs Y said yes and pointed to the shower room and corridor. The Deputy Manager and Deputy Nurse asked to speak to Ms Q who subsequently telephoned Mrs X in tears. She said they spoke to her about how Mrs X and Ms Q made staff feel during their visits with the concerns they were raising. When Mrs X visited later that day, the Manager asked to speak to her; it was for a repeat of the meeting with Ms Q. The meeting was in a small office with the Manager, Deputy Manager and Deputy Nurse. Mrs X says the managers “stood over” her which made her feel intimidated. The Care Provider says the Deputies only joined the meeting because they heard Mrs X shouting. Mrs X does not agree with this. The managers told Mrs X the staff said Mrs X and Ms Q made them feel uncomfortable because they were always raising concerns. They also felt Mrs X and Ms Q were accusing staff of causing the marks on Mrs Y’s arms. Mrs X says this was not the case and they only wanted to know why it wasn’t recorded on the system, and if staff could explain what caused the marks.
25. There was not a consensus on when the marks appeared on Mrs Y and no one knew how they had happened. Mrs X asked the GP to attend and he arranged for a blood test, she says he asked staff to be more careful with Mrs Y. The Manager said they could not provide 1:1 care for Mrs Y.
26. Early in Mrs Y’s stay, the records note that Mrs X was overwhelmed by the situation of Mrs Y being in a care home. It said Mrs Y and the family needed time to adjust
27. The day after the two meetings between the managers and Ms Q, then Mrs Z, the family confirmed a two week extension to Mrs Y’s stay at Tallington Lodge.

Male staff providing personal care to Mrs Y

28. Mrs Y’s care plan “Memory and Understanding” says: “I am very nervous of men & have a female only to attend to my needs”. The care plan for “Hygiene and Personal Appearance” says: “[Mrs Y] prefers a FEMALE carer only”.
29. There are records which appear to be by male staff on Mrs Y’s record, most of which relate to providing meals and refreshments. However, on one occasion, a record relating to personal care was completed by a care worker the Care Provider has confirmed as male. This says “[Mrs Y] was up and half dressed on arrival assisted [Mrs Y] to the lounge.”. There are no records of Mrs Y not complying or being distressed at this time. The Care Provider says “half dressed” referred to Mrs Y not having a cardigan on at the time however, this is not recorded.

Dressing Mrs Y inappropriately

30. Mrs Y’s care plan for hygiene and personal appearance says: “[Mrs Y] will sometimes choose her own outfits, the care team are to ensure that [Mrs Y] is dressed weather accordingly.”.
31. On one occasion, Mrs X noticed Mrs Y’s top was not sitting right and went to adjust it. Mrs Y was wearing a black bra that was too large and not hers. She alerted a care worker who offered to change the bra but Mrs X did it herself. She said Mrs Y also had shoes on which were very big and her support socks had the soles on top of her feet. The Care Provider said the bra was loose but did belong to Mrs Y. It says another family member confirmed this, although Mrs X disputes this. The Care Provider also says that Mrs Y was often independent with dressing and may have put these items on herself.

Not replacing hearing aid batteries

32. Mrs Y’s “Communication capability” care plan says “[Mrs Y] has hearing aids but does not like to use them but is able to place them herself. The batteries require changing weekly.”.
33. On most, but not all, days, the Care Provider’s records note either “assisted”, “independent”, or “declined”, with regards to her hearing aids. On the remaining days there was no record at all. There is no mention of changing batteries anywhere. The Care Provider says staff always check the aid is working before putting them on but does not specifically record this. It says it has learnt a lesson from this case.

Mrs Y dentures

34. Mrs Y complained about the way the Care Provider dealt with the problem Mrs Y had with her dentures, which were loose. Her care plan for “Food, Nutrition & Meal Times” says: “I tend to remove my dentures when eating as food gets stuck under my plate & this causes me discomfort.”. It gave no actions for staff to take around this.
35. The case notes mention several occasions when Mrs Y removed her dentures at the dining table. On other occasions the records note that other residents were finding it “off putting”. The first noted that a member of staff gave her a bowl of water to wash the dentures. The Deputy Manager recorded that this was not appropriate, and that Mrs Y should not be encouraged to remove her dentures at the table in future. Mrs X said when she asked the Deputy Manager about this, she said she had made Mrs Y put them back in. Mrs X was upset by this and thought this could have been handled differently. Mrs X says she understood why people found it off putting. She says the Deputy Manager spoke down to her when she asked if Mrs Y could eat in her room because there were not enough staff to supervise Mrs Y alone in her room. The Care Provider disagrees that the Deputy Manager would speak in that way. The outcome of the discussion was that the Care Provider decided Mrs Y should sit near the doorway out of the sight of other residents, but where the staff could still monitor her. Mrs X agreed to this to save Mrs Y from unnecessary attention from “angry residents”. However, she also feels this is a form of shaming and should not be tolerated. I would describe the seat where Mrs Y was placed as near the doorway rather than, as Mrs X describes it, “in the doorway”. The Care Provider’s investigation found the family had been advised to book a dental appointment which did not happen before the end of Mrs Y’s respite stay towards the end of June. This would potentially have resolved the problem with her dentures. It did not uphold the complaint about this.

Staff being aggressive when questioned about these issues

36. Mrs X and Ms Q found the approach of the Manager, Deputy Nurse, and Deputy Manager in particular, aggressive. The Care Provider strongly disagrees.
37. The Care Provider’s investigation report said the manager and deputies had said Mrs X was “aggressive and patronising” and had been shouting in the meeting with them. The investigation report recognised there had been a breakdown in the relationship and trust between family and staff at the home. It said it had spoken to staff and management about dealing with challenging situations at work. It also said that, although it had not upheld Mrs X’s complaint about this, it would monitor these areas.

The Care Provider’s investigation and complaint response

38. Mrs X was unhappy with the investigation report which she says did not consider all her complaints and, she felt, took the word of staff over Mrs X. The Care Provider’s investigation did not compare the care plan with the care staff gave and did, to some degree, take staff member’s comments without question. For example, it did not pick up that there were no actions for staff to deal with Mrs Y’s tendency to remove her dentures at the table. Or that the care plan for continence needs required two hourly checks which were often not completed in full.
39. The Care Provider’s investigation also did not deal with the issues around weight loss, male staff providing personal care and hearing aid batteries. In response to my draft decision, the Care Provider said Mrs X had not previously raised these issues although Mrs X says she did. However, as the Care Provider had responded to me about these issues, it was proportionate for me to continue my investigation into them.

Did the Care Provider’s actions cause injustice?

Medication left in Mrs Y’s room

40. I have not come to any conclusion over the medication issue. There is no evidence to support either of the opposing views. The Care Provider says it carried out random checks and will continue to do this. This is an appropriate response under the circumstances.

Weight loss

41. Mrs Y was only at the home for five weeks. She should have been weighed on entry and at least once more. The records show this was completed. There was no injustice here.

Mrs Y left in soiled pads and checks not increased as agreed

42. Mrs Y’s care plan was clear about the two hourly checks but this was not routinely done. Whether the Manager offered the checks or not, it was in the care plan and needed to be done. The records show that staff did not complete Mrs Y’s care as planned. At one point, Mrs Y was found to have a urinary tract infection which the two hourly checks were designed to help prevent. However, there were also records which showed appropriate action taken in response to concerns linked to urine output. This does raise questions about how the Care Provider met Mrs Y’s needs on those few days when staff made only three or fewer checks. This put Mrs Y at an increased risk of harm on those days when two hourly checks were not completed, however, this was limited because on most days staff made four or more checks.

No explanation or records for bruises and abrasions

43. It is not always possible to provide explanations for bruises and marks on older people especially those who are independently mobile. It was also noted in Mrs Y’s records that she bruised easily. However, the purpose of recording bruises and other injuries is to monitor so any cause might be identified. As the Care Provider had noted, Mrs X had handed over the care of Mrs Y to the Care Provider and was anxious to ensure she came to no harm. It is clear Mrs X and her family were more attentive to the smaller details of Mrs Y’s care than most might be. The marks and bruises should have been recorded and staff should have been better able to explain to the family about why it is not always possible to understand what has happened. This caused Mrs X undue stress and anxiety. As the family extended Mrs Y’s stay shortly after the difficult meetings, I conclude, on the balance of probability, their concerns about the care were limited.

Male staff providing personal care to Mrs Y

44. It was clear in Mrs Y’s care plan that she should not be supported by male staff in her toileting and personal care. There was no record to explain why a male care worker attended her for personal care. Fortunately, Mrs Y was does not appear to have been distressed by this and it may be that it was because the male care worker did not support her with very intimate care. I am satisfied, on the balance of probability, that the male care worker did not assist Mrs Y with any personal care. There is no injustice here.

Dressing Mrs Y inappropriately

45. On one occasion Mrs Y was wearing the wrong bra, shoes and her socks were upside down. Mrs Y was often independent with dressing so we do not know whether Mrs Y put these on herself or whether it was staff. Staff offered to change the bra when alerted; this was suitable action to take and there is no injustice here.

Not replacing hearing aid batteries

46. The care plan said the batteries needed changing weekly therefore staff should have changed the batteries weekly and recorded this.
47. However, it is unclear whether staff ever changed the batteries because there is no record. This is important to someone with hearing loss and caused risk of harm to Mrs Y’s wellbeing and dignity.

Mrs Y dentures

48. The home could not arrange for new dentures when Mrs Y was only there for a short time. There are no records of how the Care Provider came to this decision about where Mrs Y should sit, and whether it considered alternatives. However, I am satisfied the Care Provider found the most suitable arrangement to balance Mrs Y’s needs with those of the other residents. I found no injustice here.

Staff being aggressive when questioned about these issues

49. Mrs X and the Care Provider have opposing views over the approach of staff. However, Mrs X and her family were finding it difficult dealing with a new situation, and this was noted in the Care Provider’s records. I am satisfied, on the balance of probability, that staff did not deal well with Mrs X’s repeated challenges. Staff should be used to anxious relatives, and sufficiently confident in their delivery of care and support, to counter challenges politely and supportively. It should not have needed three managers to speak to Mrs X and I accept this felt intimidating to her. If she was raising her voice, it was unlikely this would calm the situation. This caused Mrs X significant stress and anxiety however, the Care Provider took appropriate action and the outstanding injustice here is limited.

The Care Provider’s investigation and complaint response

50. The Care Provider’s investigation did not enable the Care Provider to respond to Mrs X’s complaint adequately. This was because it did not reference the care plan as the standard to which staff should be providing care. This caused frustration and stress to Mrs X as she felt the Care Provider did not recognise the issues she raised. The Care Provider should have identified the shortfalls in continence care and recording of bruises and similar marks. These were issues of which it was aware in Mrs X’s formal complaint.
51. I am pleased to note that the Care Provider did recognise the breakdown in the relationship between family and staff. The action it took in speaking to staff and managers about dealing with challenging situations indicates it recognised there was a problem. This was appropriate action to take and for the most part, the Care Provider took similarly appropriate action in response to the other issues about which Mrs X complained.

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Recommended action

52. To remedy the injustice caused, I recommended the Care Provider:
• Apologise to Mrs Y (if appropriate), Mrs X and the family for the injustice identified above and setting out the actions it will take to avoid this in future.
• Review the effectiveness of its recording systems and processes and identify how the gaps noted above have arisen.
• Ensure all staff and managers receive further training in recording actions and following care plans.
• Review how complaint investigations are conducted and put in place arrangements to improve the way it responds to complaints.
• Provide evidence of these actions to me. Suitable evidence would include a copy of the apology letter and an action plan showing progress on the remaining actions.
• Complete the first recommendation within one month of my final decision and the remainder within three months.

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Final decision

53. I have completed my investigation and uphold Mrs X’s complaint. I found the Care Provider caused injustice which will be remedied by the recommended actions.

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Investigator's decision on behalf of the Ombudsman