Summary: We have not found fault in the way the Home managed Mrs D’s nutrition. There was fault in the Home’s complaint response regarding the delay in obtaining the cream and the skin condition and it would have been good practice for the Home to chase the arrival of the cream more. There was fault in the cleanliness of the room on 5 January 2022. We have recommended that the Home apologises to the family and pays £150 to acknowledge the distress the fault caused.

The complaint

1. Mrs C complains on behalf of her parents, Mr and Mrs D. Mrs D has, sadly passed away.
2. Mrs C’s complaint relates to the Adelaide Lodge Care home. She complains about the Home’s nutrition, cleanliness and says it did not properly provide care to address Mrs D’s skin condition.

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The Ombudsman’s role and powers

3. 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)
4. 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

5. I have discussed the complaint with Mrs C. I have considered the evidence she and the Home have sent, the relevant law and guidance and both sides’ comments on the draft decision.

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What I found

Standards of care

6. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
7. 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. This says:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• The nutritional and hydration needs of the service user must be met. Where a person is assessed as needing a specific diet, this must be provided in line with that assessment (regulation 14).
• Premises and equipment must be clean. The service provider must maintain standards of hygiene appropriate for the purpose (regulation 15).

Background

8. Mr and Mrs D moved into the Home on 7 December 2021 and moved out on 5 January 2022.

Complaint – 16 January 2022

9. Mrs C complained to the Home on 16 January 2022 and said she was dissatisfied with the level of care and service her parents received while they stayed at the Home. She said:
• She noticed on 4 December 2021 that her parents’ room was not clean. She asked staff when the room would be cleaned and they informed her it would be cleaned on 6 December 2021, but that did not happen.
• Mrs D had a sore and broken area between her buttocks which needed attention and dry skin on her arms and legs which required daily application of a cream. Ten days passed before Mrs D had a shower at the Home or the broken area on the buttocks was checked.
• The food at the Home was of poor quality and portion sizes were small. Mrs D had problems with her stomach and had not been eating much at the Home. She was ill with sickness and diarrhoea before Christmas and was taken to hospital on 4 January 2022. Mrs C thought this may be linked to a hygiene problem at the Home.
10. Mrs C also said she went to collect her parents’ belongings on 8 January 2022 and was ‘appalled’ at the state of her parents’ room:
• The mattresses, mattresses protectors and bedding were soiled.
• The shower drain was not clean and was blocked.
• She had drilled holes in the wall when her parents moved in and the dust and debris from those holes was still on the floor.
• There was a thick layer of dust on the wardrobe and the furniture was not clean.
• The commode was stained with urine and faeces and there was excrement on the toilet seat and hardened toilet cleaner in the pan.
• The hot water in the tap gushed out for a few seconds and then ran to a dribble.

Home’s response – February 2022

11. The Home responded and said:
• It had no knowledge of the conversation on 4 December 2021.
• The Home had a meeting about the meals with Mr and Mrs D. Mr D did not lose any weight during his time at the Home. Mrs D had underlying health issues which may be linked to the weight loss.
• It outlined the days when Mrs D had a shower (see below – paragraph 21).
• Mrs D was seen by the district nurse on 16 December 2021 in relation to the skin on her buttocks when a cream was prescribed. The Home chased the arrival of the cream on 21 December 2021. The cream arrived on 23 December 2021.
• The Home never received the list of foods that Mrs D could not or did not like to eat. It was aware that Mrs D could not eat spicy foods.
• The Home ensured Mrs D was seen frequently by medical staff in relation to her stomach/intestinal medical conditions.
• The Home spoke to the family on 2 January 2022 and explained that it was monitoring Mrs D’s weight and said it could put in place a MUST (Malnutrition Universal Screening Tool) plan where it would record Mrs D’s daily nutrition and provide her with high calorie foods and supplements.
• There was no indication that the hospital admission related to poor hygiene. The GP said the admission related to possible colitis.
12. In response to the state of the room on 8 January 2022, the Home said:
• Mr and Mrs D left the Home on 5 January 2022 and the room was locked to stop anyone entering the room to safeguard their belongings. This why the room had not been cleaned when Mrs C came to collect the belongings on 8 January 2022. The Home said this explained the state of the bedding.
• It had not witnessed the dust on the floor or on top of the wardrobe so it could not comment.
• The commode had been removed from the room so the Home could not comment on the state of the commode.
• It admitted the shower drain was not clean and said it had put in monitoring practices to ensure this did not happen again.
• In terms of the toilet, it said it had checked the toilet and there was a little brown stain on the raiser. The Home could not ensure the toilet was cleaned after each use.
• The tap was fine if it was turned on halfway. This had been done on the advice of the CQC to prevent residents getting scalded.
13. Mrs C wrote to the Home on 5 March 2022 as she had a lot of questions following its response to the complaint. The Home did not provide any further response.

The Home’s records

14. I have read the Home’s records relating to the Mrs C’s three complaints: nutrition, monitoring of Mrs D’s skin and cleanliness of the room.

Nutrition

15. The Home’s nutrition care plan for Mrs D said Mrs D was able to eat her meals independently. Mrs D had medical conditions affecting her digestion. Coffee and spicy foods irritated her stomach. Mrs D’s weight had to be monitored weekly for the first four weeks.
16. The records showed:
• 14 December 2021. Weight loss of 0.6 kg. Staff to continue weighing Mrs D weekly.
• 21 December 2021. Weight loss of 0.9 kg. Staff to monitor.
• 22 December 2021. The Home’s staff had a meeting with Mr and Mrs D about the meals. Mr D said the food at the Home was too bland. Mrs D said she had a list of foods which upset her. She remembered some of the items on the list and told the Home.
• 26 December 2021. The Home rung the GP as Mrs D had had a stomach pain for 4 days and not eaten anything. The GP visited Mrs D and thought Mrs D had a build-up of acid in her stomach and increased her medication.
• 28 December 2021. Weight loss of 0.7 kg. Mrs D had stomach pains and nausea so had little appetite. Staff were monitoring.
• 29 December 2021. The GP examined Mrs D and noticed that her temperature had increased. The GP thought Mrs D may have an infection. He said the Home should obtain a urine sample and he would organise a blood sample to be taken. He prescribed an anti-sickness drug.
• 29 and 30 December 2021. The district nurse tried to take Mrs D’s blood but was unable to do so.
• 4 January 2022. Weight loss of 2.1 kg. Staff were to encourage a high calorie diet and drinks and completion of meals.
• 4 January 2022. The GP visited because Mrs D was feeling cramps, was not eating and drinking much. Mrs D was admitted to hospital with possible colitis.
• Mrs D’s weight was 57 kg when she arrived at the Home and 52.7 kg when she left.
17. The Home has sent me Mrs D’s Malnutrition Universal Screening Tool (MUST) record. MUST calculates risk of malnutrition based on BMI, but also the percentage of weight loss during a specific period.
18. Mrs D’s MUST record showed that Mrs D’s BMI was 24 when she arrived. A healthy BMI is between 20 and 25. Mrs D’s BMI remained at 24 during the first 2 weeks of her stay and decreased to 23 on 28 December 2021. The MUST score was 0 (low risk) on 7, 14, 21 and 28 December 2021 and 1 (medium risk) on 4 January 2022.

Skin condition

19. The care plan said Mrs D did not have any creams prescribed, but when she did, the staff should administer them.
20. The daily record for 7 December 2021 showed that Mrs D had a ‘sore bottom’ when she arrived at the Home and the district nurse should look at this when they next visited. In the following days, photos were taken of the area on 7, 13 and 14 December and the situation was monitored. The records showed the pressure areas were checked frequently.
• 16 December 2021. The district nurse visited Mrs D regarding the sore bottom. The district nurse advised the Home to apply cream to Mrs D’s bottom twice a day and asked Mrs D to move around the room to keep the blood circulating.
• 21 December 2021. The daily records said Mrs D’s bottom was still pink and the staff should report it to the district nurse and ask them for cream to be prescribed. There was then a record of a visit by the district nurse on the same day, although the visit is classed as ‘out of home’ so it is my understanding this refers to a telephone conversation. The district nurse said she would prescribe a cream for Mrs D’s bottom.
• 28 December 2021. Mrs D’s bottom was vulnerable but intact.
• 30 December 2021. The Home started to apply the cream.
21. The records showed Mrs D had a shower or bath on 11, 15, 18, 25 and 29 December 2021.

Bed changing and cleaning

22. The bedding records showed Mrs D’s bed was changed on 7, 14, 21 and 28 December 2021 and 4 January 2022.
23. The Home has sent me the daily cleaning rota for 6 December 2021. Cleaning tasks are set out individually including:
• Hoover hard floor and wash skirting boards weekly. The records showed that he cleaning staff said they had done this five times during the week of 6 December 2021.
• Dust furniture and tops of pictures daily. The records showed this was done daily.
• Clean toilet, sink and bathroom floor daily. The records showed this was done daily.

Further information

24. Mrs D was taken to hospital on 4 January 2022 and Mr D moved out of the Home on the following day. Mrs C has provided photos of Mr and Mrs D’s room on 8 January 2022 when she collected her parents’ belongings. These photos showed:
• The drain in the bathroom was clogged up with black dirt and hair.
• There were multiple stains on the mattress, mattress protector and sheets.
• There were white particles (similar to speckled dust) on the skirting board and the floor next to the skirting board.
• There were stains on the seat of the commode.
25. The Home provided the additional information to the Ombudsman:
• The bedrooms were cleaned daily. I asked how the Home monitored the cleanliness of the rooms. The Home did not really answer the question except to say that there was a cleaning rota.
• The Home said that bedding was changed once a week and the bedding was monitored. It would be changed if it was soiled. In addition, the bedding was monitored by the night staff and documented in sleep monitoring.
• I asked whether Mrs D’s daily nutrition intake was monitored. The Home said it was not as Mrs D scored 0 (low risk) on the Malnutrition Universal Screening Tool when she was admitted. She had a MUST score of 1 on 4 January 2022, but before that her score remained 0.
26. I asked the Home whether it accepted the evidence of the photos that Mrs C had sent of the bedroom on 8 January 2023. I noted that Mrs C had sent those photos to the Home when she made her complaint but the Home had not commented on them. However, the Home had said, in its previous complaint response that it could not comment on the allegations of lack of hygiene as the room had been cleaned by the time the complaint was made and the manager investigating the complaint had not witnessed the dirt described by Mrs C.
27. The Home said it did not accept the evidence of the photos. It repeated the argument that the room had been locked from 5 to 8 January 2022 and referred to the cleaning schedule as evidence that the room had been cleaned.
28. After the draft decision, the Home said the cleanliness of Mr and Mrs D’s room had been brought up at the management meeting and a new form had been introduced to check and monitor the cleaning. The cleaning supervisor, the Home’s manager and the director all monitored the cleaning. The cleaning supervisor allocated necessary tasks every day and monitored them.

Analysis

Nutrition

29. I share Mrs C’s concern that Mrs D lost 3.4 kg in a short period of time and that she had to go to hospital. However, that, in itself, is not evidence that there was fault in the Home’s actions.
30. I can only investigate whether there was any fault in the way the Home managed Mrs D’s nutrition and responded to any medical conditions. The Home did not keep a record of the actual food Mrs D ate so I cannot comment on the quality of the food or the portion sizes.
31. The care plan said Mrs D should not eat spicy foods or coffee and there is no indication that the Home deviated from that plan.
32. Mrs D’s weight was monitored on a weekly basis, in line with the care plan, so I find no fault in that respect.
33. I did question whether the Home should have kept a record of what Mrs D ate and drank from the time she moved it. However, I note that the Home monitored Mrs D’s risk of malnutrition in line with the MUST guidelines and that was good practice. Mrs D was at low risk of malnutrition during her stay. She scored ‘medium’ risk on 4 January 2022, but she then went to hospital. I note that the Home was considering putting a MUST plan in place at the time.
34. I note that Mrs D’s weight deteriorated in the last 9 days of her stay at the Home and she lost 2.1 kg during the last week. However, at this stage it appeared there was an underlying medical problem. Mrs D was complaining of stomach pains and nausea and this affected her ability to eat.
35. The Home obtained medical advice which was an appropriate response and I find no fault in this approach. The GP visited Mrs D on 26 and 29 December 2021 and on 4 January 2022 and the Home was led by the GP’s advice.

Skin health

36. Mrs C complained that Mrs D did not have a shower and did not have her skin checked until 10 days after she moved in. I do not uphold that complaint. The records showed that Mrs D moved into the Home on 7 December 2021 and had a shower on 11 December 2021. The skin on her buttocks was checked and photos taken on 7, 13 and 14 December 2021.
37. In the Home’s complaint response dated 5 February 2022 the Home said that the district nurse prescribed a cream for Mrs D’s buttocks on 16 December 2021, and the district manager chased this on 21 December 2021. The cream arrived on 23 December 2021.
38. The Home’s complaint response to the Ombudsman and its records contradicted this version of events.
39. The records showed that the district nurse visited on 16 December 2021 and said the Home should put cream on Mrs D’s buttocks, but the Home’s records did not specify whether this should be a prescription cream or a generic cream. The Home then chased the district nurse for the prescription on 21 December 2021. The district nurse issued the prescription, but the Home said the cream did not arrive until 30 December 2021 (not 23 December 2021) when it started to apply the cream.
40. If the cream did not arrive until 30 December 2021, as the Home now says, then there were several delays, firstly the delay from 7 December 2021 when the Home said Mrs D should be seen by the district nurse until 16 December 2021 when the district nurse visited Mrs D. There was then a delay in the prescription of the cream between 16 and 21 December 2021. And finally, there was a delay from 21 December 2021 when the cream was prescribed until 30 December 2021 when the cream arrived. However, I accept that the fault may not lie with the Home and, unfortunately, I cannot investigate the actions of the district nurses.
41. There was, of course, some fault in the Home’s complaint response dated 5 February 2022 as this response did not reflect the records. The response said the cream had arrived on 23 December 2022 and, although it was not expressly said, it was implied that the cream had been applied since that day. That was not the case.
42. I am also of the view that it would have been good practice for the Home to chase the issue more. The Home only chased the matter once, on 21 December 2021, when it asked the district nurse to send the prescription.

Cleanliness

43. I have considered the evidence that has been provided from both sides in relation to the cleanliness of Mr and Mrs D’s bedroom. Mrs C has provided evidence of the condition of the room on 8 January 2022. There is no indication that these photos are not real or have been faked in any way.
44. The Home does not accept the evidence of the photos. The Home’s first reason to dismiss the evidence was to explain that the room was not cleaned between 5 and 8 January 2022. I accept this, but that does then, suggest that the Home accepts that the photos reflect the condition of the room on 5 January 2022. The Home has never explained why the room was left in such a poor state on that day.
45. The Home’s second argument to counter the photos was to refer to the cleaning schedule. I accept that there was a cleaning schedule and, although I have not seen the rota for that week, I accept that the cleaners may well have signed off the rota. However, that does not mean that the cleaning was done properly.
46. I accept the Home’s third argument that, occasionally, the toilet may be dirty as it could not clean it every time it was used.
47. However, that does not explain the overall condition of the room on 5 January 2022, as evidenced by the photos, particularly the drain in the bathroom which was clogged up with black dirt and hair, the multiple stains on the mattress, mattress protector and sheets, the dust on the skirting board and the floor next to the skirting board, the general dust and the stains on the seat of the commode.
48. I therefore uphold Mrs C’s complaint about the condition of the room on 5 January 2022 and I accept that this would have affected Mr and Mrs D and the family.

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Recommended action

49. I recommend the Home takes the following actions within one month of the final decision. The Home should:
• Apologise in writing to Mrs C and Mr D for the fault I have identified.
• Pay the family £150 for the distress caused by the fault.

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Final decision

50. I have completed my investigation and have found that the Home’s actions have caused an injustice. I have recommended a remedy to address the injustice.

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Investigator's decision on behalf of the Ombudsman