Summary: Mrs C complains about the standard of care provided by the Care Provider. The Care Provider is at fault for failing to retain and record interventions which has caused uncertainty about whether it cared for Mrs C’s mother, Mrs D, properly. The Care Provider has accepted some fault, apologised, agreed to pay Mrs C £500, and take action to improve future practice. To reflect the further faults I have found, the Care Provider has agreed to make further service improvements including reminding staff about recording contemporaneous daily records and completing nutrition and toileting plans.

The complaint

1. The complainant who I call Mrs C complains about services provided to her late mother, Mrs D, from Fountains Care Home. The care home is managed by Barchester Healthcare Homes Limited, the “Care Provider”.
2. Mrs C complains the care home was inadequate. It:-
1. lost clothing;
2. did not properly support Mrs D with her personal care and continence;
3. did not use personal toiletries;
4. dressed Mrs D in other people’s clothing;
5. did not provide sufficient nutrition to Mrs D;
6. left soiled items in Mrs D’s room and drawers;
7. posted pictures of Mrs D in her nightclothes on social media without permission.
3. Mrs C says as a result of these failures she and Mrs D were caused distress. The Care Provider’s actions also caused Mrs D indignity.

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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 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)
5. 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)

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How I considered this complaint

6. I spoke with Mrs C and considered information she sent. I made enquiries of the Care Provider and asked it several questions. I also considered:-
• care records;
• 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. I have used the fundamental standards as a benchmark for considering this complaint.
7. Mrs 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

Background information

8. Mrs D’s daughters supported her in the community. However because of several unavoidable reasons they needed respite care for Mrs D. This was a difficult decision, but they chose the Fountains Care Home.

What should have happened

9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve.
10. Regulation 10 says care providers must make sure they provide care and treatment in a way that always ensures people's dignity and treats them with respect.
11. Regulation 12 aims to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Care providers must assess the risks to people's health and safety during any care or treatment and act to mitigate risks.
12. Regulation 14 says care providers must meet service user’s nutritional and hydration needs. The associated guidance says care providers,
13. “must include people's nutrition and hydration needs when they make an initial assessment of their care, treatment and support needs and in the ongoing review of these. The assessment and review should include risks related to people's nutritional and hydration needs. Providers should have a food and drink strategy that addresses the nutritional needs of people using the service.”
14. Regulation 17 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

15. Mrs D entered the care home for three weeks respite in August 2021. The Care Provider told family not to visit in the first week. When family visited they were shocked by Mrs D’s appearance. They noticed:-
• unopened toothpaste and toothbrush;
• smell of urine;
• incontinence pants on the floor;
• other people’s clothing in Mrs D’s wardrobes even though all Mrs D’s clothing was labelled;
• soiled towels in the drawer.
16. Mrs C complained to the care home who were very apologetic and said this was a “one off”. Mrs C told the care home she would never let her mother return. In October Mrs C needed emergency respite for Mrs D. Although Mrs C was unhappy with the care previously provided, following reassurance from the care home Mrs D returned for a week.
17. When Mrs C collected Mrs D she says she looked dishevelled, her hair uncombed, she was not wearing her own trousers, and staff had thrown all her belongings into a suitcase, many of which did not belong to Mrs D. Mrs C and her sister had to find a carer to shower Mrs D as she was wet all through her trousers. Mrs D’s trousers were so big she had to hold them up while walking. When showering Mrs D, Mrs C noticed Mrs D’s unopened soap bag.
18. Mrs C complained to the care home. She says the staff were apologetic and originally offered a refund of the care fees. Mrs C complained in writing and met with the care home to try and resolve matters. The Care Provider did not fully answer all Mrs C’s complaints and after making further comments the Care Provider responded saying:
1. the Care Provider used the care home’s toothbrush, toothpaste, and toiletries and this was why staff had not opened the wash bag. The Care Provider apologised for the failure of staff to use Mrs D’s personal toiletries;
2. the Care Provider apologised for Mrs D wearing the wrong trousers. It said it would remind staff and housekeeping about residents wearing their own clothes and putting the correct clothing in residents’ rooms;
3. apologised for the way in which staff packed Mrs D’s suitcase and said it had spoken with relevant staff members;
4. apologised for the failure to complete an inventory which resulted in Mrs D losing belongings. It said it now had a tagging system which would ensure staff returned people’s belongings correctly and it also now completed an inventory when new residents entered the care home;
5. apologised for putting pictures on Facebook without consent. The Care Provider said it had removed the pictures and provided refresher training to staff about the use of photographs;
6. made an offer of £500 as a goodwill gesture because of the faults identified.
19. The Care Provider did not uphold the following complaints:
1. the manager witnessed carers support Mrs D with personal care and changing her trousers after lunch. The Care Provider said the soiling must have happened after this;
2. apologised for the soiled items found in the bedroom, but said Mrs D was on her own for some periods of time and could remove her incontinence pants;
3. Mrs C said Mrs D lost weight while at the care home. The Care Provider said it had no major concerns about food and nutrition for Mrs D but noted that she had a small appetite. As there were no concerns and it was a short stay they did not complete a food and fluid monitoring check list. They did however advise Mrs C to contact Mrs D’s GP for a referral to a Speech and Language Therapist to support with Mrs D’s diet. Mrs C says Mrs D lost a total of 11 pounds during her stays at the care home.

Is there fault causing injustice?

20. The Care Provider’s early acceptance of fault, actions to improve future practice and good will gesture is welcomed and suitable to remedy some of the complaints made. In particular potential breaches of Regulations 10 and 12 detailed above.
21. The Care Provider cannot provide records for Mrs D’s first stay or details of Mrs D’s care plan for nutrition or continence for the second stay. The failure to keep and store records is fault and a potential breach of Regulation 17.
22. The daily records for the second stay lack detail about what, and how much Mrs D was eating and drinking; some days only have a single record. There is also no eating and drinking plan. This is fault and a potential breach of Regulation 14.
23. The Care Provider identified Mrs D needing help with her continence and changing her incontinence pants. The records show staff only checking Mrs D’s continence pants once a day during her second stay. This is fault and a potential breach of Regulations 10 and 12.
24. Due to the lack of records Mrs C has the uncertainty of not knowing if staff properly supported Mrs D with her teeth, continence needs and whether Mrs D’s condition the day Mrs C picked her up, was an isolated case.
25. Mrs D had the indignity of wearing someone else’s clothing and not having her incontinence, food or fluid monitored as it should have been. Mrs C has the uncertainty that but for the faults identified Mrs D would not have lost weight.
26. Mrs C also has the upset, frustration, time, trouble and guilt the care she arranged for her mother was not to the standard it should have been.

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Agreed action

27. The Care Provider has accepted fault and I have found further fault which has caused Mrs C and Mrs D injustice. Mrs D has now passed away and I cannot remedy her personal injustice. The Care Provider has agreed to take the following additional actions to remedy the complaint:-
1. the Care Provider has apologised to Mrs C and offered a payment of £500. The payment is in line with what I would have recommended in this case. The Care Provider should however apologise to Mrs C for the further faults I have found;
2. review procedures to ensure the same level of nutrition assessment and recording for long, and short term residents and train staff accordingly;
3. provide evidence of the actions the Care Provider agreed to take as part of the complaint response. This includes:-
1. reminding staff of the importance of using people’s own toiletries, ensuring residents are wearing their own clothes,
2. evidence of refresher training provided about posting pictures and the content of those pictures,
3. evidence of a new tagging system which will help ensure clothes are in the correct room.
4. remind care staff about completing a continence plan for residents;
5. remind staff about the importance of completing daily records with a suitable level of detail.
28. The Care Provider should complete (a) within one month of the final decision and (b) to (e) within three months of the final decision.

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Final decision

29. I have found fault causing injustice. I consider the agreed actions above are suitable to remedy the complaint. I have now completed my investigation and closed the complaint.
30. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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Investigator's decision on behalf of the Ombudsman