Summary: Mrs X complained about the care her husband, Mr X, received at Carlton Court Care Home. Rockley Dene Homes, which owns Carlton Court, has already stated it was at fault in some areas, including his social interactions, communications with Mrs X and one incident relating to Mr X’s physical wellbeing. The care provider has already apologised to Mrs X and said it has made appropriate service improvements to prevent a reoccurrence. As a remedy, it should provide evidence of this.

The complaint

1. Mrs X complained that Carlton Court Care Home failed to provide her husband, Mr X, with suitable care, leading to her having to remove him and arrange care elsewhere.
2. Mrs X made the following complaints to Rockley Dene Homes;
1. on 20 May 2021, Mr X’s daughter witnessed him left cold and under-dressed in an unhygienic room without key items in reach and without encouragement to eat his food;
2. Mr X did not have enough social interactions, or wellbeing activities, during his stay;
3. care staff failed to facilitate daily video calls between Mrs X and Mr X and failed to ensure he could access his mobile phone throughout the day;
4. Mr X’s medication patches were not applied correctly;
5. Mr X’s incontinence was poorly managed leading to bedwetting;
6. Mr X’s medical spray and cream were not administered properly;
7. Mr X was ‘disheveled’ and not showered frequently enough;
8. Mr X’s food and drink intake was not properly managed during his stay, causing weight loss and dehydration;
9. care staff allowed Mr X to sleep in an armchair all night on one occasion;
10. Mr X’s care records showed an accident occurred but the records for this date had been amended; and
11. Mr X was not encouraged to walk during his stay and lost mobility.
3. Mrs X said the poor care her husband received caused them both distress for the period of three weeks he resided at the care home.

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The Ombudsman’s role and powers

4. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H)
5. We may investigate complaints from the person affected by the complaint issues, or from someone they authorise in writing to act for them. If the person affected cannot give their authority, we may investigate a complaint from a person we consider to be a suitable representative. (section 26A or 34C, Local Government Act 1974)
6. If we are satisfied with an organisation’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)
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

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How I considered this complaint

8. I considered the information provided by Mrs X and the care provider.
9. I considered the relevant law and guidance as set out below.
10. I considered our Guidance on Remedies.
11. I considered comments made by Mrs X and the care provider on draft decisions before making a final decision.

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Law and guidance

Law, regulations and guidance in care settings

12. The Health and Social Care Act 2008 (the 2008 Act) and the Health and Social Care Regulations 2014 (the 2014 Regulations) set out standards that registered care providers must achieve.
13. The 2014 Regulations say care providers must, ‘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’.
14. The Care Quality Commission (CQC) is the statutory regulator of care services. The CQC sets out 13 Fundamental Standards which care should never fall below. It has its own guidance on how to meet these fundamental standards as well as the requirements of the 2008 Act and the 2014 Regulations. I refer to this as the CQC guidance.
15. The CQC guidance says, ‘Care providers must make sure they provide care and treatment in a way that ensures people's dignity and treats them with respect’ and ‘People using the service must not be neglected or left in undignified situations’.

Mental capacity and consent

16. The Mental Capacity Act 2005 is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves. This Act and the Mental Capacity Act Code of Practice 2005, describes the steps a person should take when dealing with someone who may lack capacity to make decisions for themselves. It describes when to assess a person’s capacity to make a decision, how to do this, and how to make a decision on behalf of somebody who cannot do so.
17. A key principle of the Mental Capacity Act 2005 is that any act done for, or any decision made on behalf of, a person who lacks capacity must be in that person’s best interests. The decision-maker must also consider if there is a less restrictive choice available that can achieve the same outcome. Section 4 of the Act provides a checklist of steps decision-makers must follow to determine what is in a person’s best interests.
18. The 2014 Regulations also describe issues around consent. They say, ‘Consent is an important aspect of providing care and treatment, but in some cases, acting strictly in accordance with consent will mean that some of the other regulations cannot be met. For example, this might apply with regard to nutrition and person-centred care’.

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What I found

What happened

19. Mrs X’s husband, Mr X, has dementia and other health conditions. He is in his eighties.
20. In May 2021 Mrs X arranged for her husband to receive respite care at Carlton Court care home.
21. Mr X received respite care at the care home for three weeks. After three weeks, Mrs X removed him from the care home due to concerns he was receiving poor care.
22. Mrs X complained to the care provider. It responded and either upheld, or partially upheld, her complaints regarding social interaction and wellbeing activities, medication patches, daily video calls, the incident of 20 May 2021 and the management of Mr X’s incontinence. It also partly upheld fault in relation to his medications.
23. However, the care provider did not agree that it was at fault regarding the regularity of Mr X’s showers, his food and drink intake, the amendment of care records, encouraging Mr X to walk, or him being allowed to sleep in an armchair.
24. The care provider was unable to come to a finding on Mrs X’s complaint about Mr X’s phone being charged and within reach.
25. As a remedy in recognition of the faults it accepted, the care provider agreed to refund the care fees for the period after Ms X removed her husband from the care home. Ms X was contractually obliged to pay the remaining costs but these were waived due to the negative feedback. The refund amounted to £2,330.36.
26. It also apologised to Ms X and committed to making several service improvements to prevent the faults happening in future.
27. The following paragraphs set out the issues complained about in more detail.

Complaint 2a) Welfare concerns on 20 May 2021

28. Mr X’s daughter said during a visit on this date, Mr X was cold, underdressed, unable to reach his call bell or walking frame and soiled pads had been left close to him and smelled. The care provider agreed Mr X was left in an unacceptable state and the situation was ‘as described’ by his daughter. The care provider apologised and said the employee responsible for Mr X’s care on this day no longer worked for them.

Complaint 2b) Social interactions and wellbeing

29. Mr X was assessed as having capacity to make choices about what activities he would do and how he would spend his days. His Care Plan said he should receive a visit from the wellbeing team daily and they should ask him whether he wanted to take part in activities. Mr X was a resident at the care home for 19 days. During this time he received 30 wellbeing visits. Of these 30 wellbeing visits, 22 of them lasted for ten minutes or less.
30. On one day during Mr X’s stay he received no wellbeing visit and no reason is provided. However, he did receive routine visits from other members of staff throughout that day. Records show the wellbeing team asked during many visits whether he would like to take part in activities. Mr X often declined and preferred to watch television or have a chat instead.
31. The care provider said wellbeing activities were provided but it could have ‘achieved more’. It also said the communication Mrs X received from the wellbeing team was not good enough.

Complaint 2c) Phone access and video calls

32. Mr X’s Care Plan said he wished to have a video phone call with Mrs X daily. The care provider facilitated the calls on most days but not all. The care provider accepted more could have been done to facilitate this.

Complaint 2d) Medication patches

33. Mr X was prescribed regular medication patches. The care provider accepted that on one day, a medication patch was applied when Mr X’s old patch was still on his body. This could cause harm but did not on this occasion. The care provider upheld this complaint and said the nurse should have looked harder for Mr X’s previous medication patch before assuming it had fallen off and applying the new one.

Complaint 2e) Incontinence management

34. Mr X’s care plan said he had ‘continence worries during the night’ and needed to use ‘continence aids day and night’. Later in the plan, this is contradicted and says his pads should be removed at night after he last used the toilet before bed.
35. The care provider’s complaint response referred to an incontinent accident in May. However, there is no evidence of this in the care records. The care provider said the member of staff responsible for record keeping that day no longer worked for them. The care provider said Mrs X’s recommendations regarding what incontinence aids he needed at night should have been given more consideration at the time.
36. In a further response to us, the care provider stated its investigation found the bedwetting incident was a one-off occurrence. In relation to the care Mr X received, it said the care notes demonstrated Mr X received the correct care, because the notes referenced care workers changing his pad during the night.

Complaint 2f) Medical spray and cream

37. Mr X’s care plan also said a medical spray was prescribed as a soap substitute for an affected area of Mr X’s body and a medical cream should be applied to this area regularly. Mrs X said his medical cream was not applied properly to his body and the care provider failed to use medical spray for his skin despite it being prescribed.
38. The care provider said it followed the advice of its own clinical team regarding the application of the cream and applied it regularly. The care notes specify that the cream was applied on some days. On others the records just say he accepted ‘all medications’, of which his medical cream was one.
39. Regarding the medical spray, the records show the clinical team discontinued the use of the spray on 29 May 2021 as it believed it did not help. According to the care plan, the medical spray remained prescribed up until this point.

Complaint 2g) Showering

40. The records show Mr X was showered on eighteen days out of his nineteen day stay. On the one day he was not showered, the records comment that his personal hygiene was good that day and he was shaving himself.

Complaint 2h) Food and fluid intake

41. Mr X was not assessed on his arrival as being at risk of malnutrition or dehydration and the care provider said his patterns of eating were not uncommon in people with dementia. His care plan said he should always have a certain amount of water within reach. Mr X’s food and drink intake was regularly monitored and recorded by care staff. His fluid intake was referred to 125 times in his care records during his nineteen day stay and his food intake was referred to 111 times.

Complaint 2i) Sleeping arrangements

42. Mrs X complained care staff allowed Mr X to sleep in an armchair all night on one evening during his stay. The care provider said Mr X was “assumed to have capacity to make decisions to sleep and rest…the team did encourage [Mr X] to go to bed, but he declined…the team were acting in [Mr X]’s best interests by respecting his wish and not causing him stress by doing something that was not in line with his wishes”. The care records show that carers checked on his safety throughout the night and the next morning.

Complaint 2j) Amended care records

43. Mr X’s care records showed that an ‘Accidents/Incidents or Near Misses Log’ was completed by a member of staff. This was shown as crossed out and said the form has been archived. The care provider said this was because a new staff member had clicked the wrong form for reporting a change in Mr X’s skin. The correct form was produced for Mr X’s skin change and the original form was archived.

Complaint 2k) Mr X’s mobility

44. Mrs X said her husband was not encouraged to walk during his stay and lost mobility. There are a few instances in the care notes of Mr X being encouraged to walk but not many. It is not in his care plan as being an outcome to achieve and the care plan mostly refers to how he can move safely and how much support he needs to walk.

My findings

Complaints 2a – 2e

45. The care provider has already upheld Mrs X’s complaints about social interaction and wellbeing activities, medication patches, incontinence care, daily video calls and the incident of 20 May 2021.
46. The evidence supports these findings and further investigation would be unlikely to reach a different finding. The care provider has apologised to Ms X for these faults. It has refunded her for the care that she was contractually obliged to pay, after she removed him from the care home. It has also agreed to provide us with evidence of service improvements it says it has carried out to prevent the faults occurring in future. This is an appropriate remedy for these faults.

Complaints 2f – 2k

47. The care provider did not agree that it was at fault regarding the regularity of Mr X’s showers, his medical cream and spray administration, his food and drink intake, the amendment of care records, encouraging Mr X to walk, or him being allowed to sleep in an armchair. The evidence supports these findings.
48. The records showed Mr X was showered on most days. On the days he did not have a shower, this was in line with his wishes.
49. Mr X’s food and drink intake was monitored and recorded very regularly and his need for a certain amount of water within reach was documented in his care plan and attended to by care staff. In one of its responses to Mrs X, the care provider acknowledged Mrs X’s concerns and stated it would have been better to have discussed this with her and documented her views in Mr X’ care plan. The care provider stated it would introduce two weekly weight checks to help determine the need for food or fluid charts.
50. There is no evidence that Mr X had an accident during his stay or that his care records were amended to hide any such accident. Mrs X asked for an explanation of the amendment of the record, and this was provided. The care provider was not at fault.
51. Mr X’s care records did not state he should be encouraged to walk. However, the care notes recorded he mobilised with a frame often. If Mrs X had concerns that encouragement to walk regularly was not in Mr X’s care plan, she could have challenged this at the time.
52. The records show Mr X’s medical cream was applied as prescribed. The care provider was not at fault. Regarding the medical spray, it is not for the Ombudsman to challenge the merits of decision making taken by the care home’s clinical team, as we are not medical professionals. They took the view that the medical spray was not helping his skin.
53. Mr X had capacity to make decisions about sleep and rest. The care provider considered what the least restrictive option was for Mr X when he said he wanted to sleep in his chair one evening. The care provider considered Mr X’s best interests by encouraging him to sleep in bed and when he declined, by checking on him through the night and morning.

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Agreed action

54. Within one month of the date of the final decision, the care provider has agreed to provide evidence that it has carried out the recommendations specified in its responses to Mrs X and the Ombudsman.

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Final decision

55. I have ended my investigation. I have found fault leading to injustice and recommended a remedy to provide evidence of service improvements.

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Investigator's decision on behalf of the Ombudsman