Summary: Mrs X, on behalf of her father Mr Z, complained about the standard of care he received during six weeks in a care home. There is evidence of fault in respect of failure to provide oral care, failure to unlock a window, failure to clean faeces in his room, providing drinks that were too hot without adequate supervision and failing to give details of the complaints procedure. Some recommendations have already been accepted to improve procedures and the Council should provide an apology.

The complaint

1. Mrs X, on behalf of her father Mr Z, complains that:

• On most occasions when she visited, she noticed there were faeces on the toilet
• The care home failed to notice that her father had deep vein thrombosis (DVT) in his legs
• The care home did not do enough to ensure her father had sufficient exercise by ensuring he would regularly and sufficiently mobilise indoors, walk outside in the garden etc. Mrs X says this was an injustice in itself and also believes it resulted in the DVT her father got.
• The care home sent her father into hospital without a staff member supporting and comforting him, even though he had dementia.
• On each visit she mentioned that it was too hot, too stuffy and there was no fresh air. As such, she always asked for his window to be opened. However, it was locked and needed a maintenance person to fix it. The care home only arranged this and opened his window a few days before he left.
• The care home failed to brush her father’s teeth; she noticed his toothpaste was still full after one month.
• On two of her visits care staff put tea in front of her father that was too hot to drink. Mrs X said her father does not have the capacity to realise that and would have burned himself if she had not intervened.
• A staff member told her that care workers referred to her father as ‘Mr Dunno’, as he was unable to respond to questions due to his dementia
• The care home failed to inform her of her rights to refer her complaint to the LGSCO.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the care provide , I have made recommendations to the Council.
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)
5. 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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How I considered this complaint

6. As part of the investigation, I have:
• considered the complaint and the documents provided by the complainant;
• made enquiries of the Council and considered the comments and documents the Council provided;
• discussed the issues with the complainant;
• sent my draft decision to both the Council and the complainant and taken account of their comments in reaching my final decision.

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What I found

7. The Council arranged for Mr Z to move into Bradeney House Nursing and Care Home, Bridgnorth, Shropshire in May 2022. Mr Z was resident at the home from 6 May to 16 June 2022, when he moved to another facility.
8. Mrs X, Mr Z’s daughter, made a formal complaint to the Care Home on 30 June. The Care Home responded to Mrs X on 21 July. The Care Home contacted the Council at the beginning of October to make it aware of the issues and to request a monitoring visit.
9. Mrs X has raised issues about the standard of care provided to Mr Z while at the home. I will deal with each issue in turn below.

On most occasions when she visited, Mrs X noticed there were faeces on the toilet

10. In her formal complaint to the Care Home dated 30 June, Mrs X mentioned two occasions when she cleaned faeces and one occasion when she sought help from staff. The Care Home says that its records show Mrs X visited six times during Mr Z’s time at the home and is aware of two dates when faeces were reported. It says one report was during a visit by other family members.
11. Mr Z’s care and support plan states that he does smear faeces and urinate in inappropriate places. As a result regular staff checks were required. I have been provided with copies of the cleaning checklists which shows his room and bathroom was cleaned on the two dates reported. The records do not indicate the time the cleaning was carried out. The cleaning records show faeces were found in Mr Z’s room on a number of occasions but not on those days.
12. It is acknowledged that it was unpleasant for Mrs X and other family members to have found this and an apology has been provided. I consider this is an appropriate response. There is nothing to suggest Mr Z was left in soiled clothing or bedding or left uncleaned for prolonged periods of time.

The care home failed to notice that her father had deep vein thrombosis

13. Mrs X visited her father on 8 June and noted that he was wearing shorts. When sitting with him, Mrs X noticed that his right leg was swollen. She raised it with the carers who said he hadn’t complained of any pain. The nurse was called and checks were carried out which were all normal. The senior nurse was also called and she decided that the doctor should be contacted. Mrs X then left to care for her children.
14. Subsequently, the home rang for an ambulance and Mr Z was taken to hospital. Mr Z was discharged the same night with a suspected deep vein thrombosis and an appointment to return for a scan two days later.
15. Mrs X says that during the day the care staff had assisted her father to change his clothes several times due to incontinence. She says she is bewildered that the swelling in her father’s leg had gone unnoticed and that it was just good luck that she was able to visit that day. She considers this is evidence of lack of care and supervision by the Care Home.
16. The information provided shows that once Mrs X alerted staff, action was taken and Mr Z received appropriate medical care including being taken to hospital. The care notes for that day do not indicate that any swelling was noticed and the Council took the view that it could not comment further as is was not possible to say when the swelling began.
17. On the basis of the information provided, I cannot find fault on this point. There is nothing to suggest any failings by the Care Home. The fact that Mrs X was the first person to notice the swelling is not evidence that staff in the Care Home ignored it. Appropriate action was taken and Mr Z received medical attention. He was discharged back to the home the same night and there is nothing to suggest he suffered any significant injustice as a result.

The care home did not do enough to ensure her father had sufficient exercise by ensuring he would regularly and sufficiently mobilise indoors, walk outside in the garden etc. Mrs X says this was an injustice in itself and also believes it resulted in the DVT her father got.

18. Mrs X believes the lack of physical exercise provided to her father while at the Care Home caused the DVT. She complained that her father only had one walk in the garden area while resident.
19. The Council says it was not given any information to indicate the cause of the DVT. The letter dated 10 June from the hospital to Mr Z’s GP made no recommendations or advice about exercise. It says that care notes indicate Mr Z walked around the home on 13 dates during his stay and that the information provide before admission made no recommendations about specific exercise. Mr Z could mobilise without support and so it was not expected that the Care Home would provided comprehensive records for how much Mr Z mobilised.
20. However, it accepts, with the benefit of hindsight, that the type and frequency of exercise could have been discussed in more detail as part of the admission process. It suggests the home includes such discission in the future.
21. I find no fault on this point.

The care home sent her father into hospital without a staff member supporting and comforting him, even though he had dementia.

22. The information provide shows that Mr Z was taken to hospital by paramedics but that no member of staff from the Care Home went with him. The Care Home has a policy setting out what happens when residents have to go to hospital. This was an unplanned visit and the policy says that where possible an escort may accompany the resident but that it is for the nurse in charge to decide at the time depending on staffing levels. If the resident attends hospital alone, then the family should be contacted to let them know about the situation so they can accompany where possible.
23. In this case, the Care Home says there were not sufficient staff on duty to allow someone to accompany Mr Z. I am satisfied the Care Home acted in accordance with its policy and so cannot find fault. I appreciate Mrs X was concerned when she learnt her father had gone to hospital without a member of staff but there is no evidence to suggest he suffered any harm or that hospital staff reported any issues when Mrs X spoke with them.

On each visit she mentioned that it was too hot, too stuffy and there was no fresh air. As such, she always asked for his window to be opened. However, it was locked and needed a maintenance person to fix it. The care home only arranged this and opened his window a few days before he left.

24. The information provided indicates the issue of the window was raised on 8 June. I note Mrs X says she had mentioned the window previously but there is nothing specific about this in other correspondence. On 8 June, staff explained that the window in the room was permanently locked as a safety precaution for a previous resident. Staff were unable to locate a key on that date to unlock the window. The maintenance logs have been provided but do not contain any entry regarding the window. It is unclear the exact date the window was unlocked but the family noted it was open the day Mr Z left the home.
25. In response to this complaint, the Council says it is possible the issue was overlooked due to other more important events on 8 June but that it should have been followed up the next day. It was fault that the window could not be opened during Mr Z’s entire stay at the Care Home. I accept this was an annoyance and may have caused Mr Z some discomfort but there is nothing to suggest it caused him a significant injustice. I note the Council has made recommendations to the Care Home about having a key safe to ensure keys are accessible to staff on shift.

The care home failed to brush her father’s teeth; she noticed his toothpaste was still full after one month.

26. It is accepted that Mr Z’s toothpaste had been hardly used when Mrs X raised the issue. Mr Z’s care plan stated that while he did not require help to physically brush his teeth he did require prompts and encouragement. The daily care records do not provide any information about oral care and so there is nothing to suggest whether staff prompted or encouraged Mr Z to brush his teeth. This is fault.
27. I have not seen any evidence to suggest this lack of oral hygiene for the few weeks Mr Z was at the Care Home caused him any significant problems. I am pleased to note the Council has made suggestions to the home on how to improve in this area including further oral care training and refreshers for staff; and more detailed record keeping. The Council says the Care Home has also introduced monthly spot checks of residents’ toothpaste and tooth brushes.

On two of her visits care staff put tea in front of her father that was too hot to drink. Mrs X said her father does not have the capacity to realise that and would have burned himself if she had not intervened.

28. Mrs X raised this issue with staff when she was present. The Care Home accepted this happened and sent a WhatsApp message to staff as a reminder not to do this, though I note this was some time after the reported incident. In response to our enquiries on this, the Council comments this was not a suitable or adequate way to communicate with staff.
29. While the staff should ensure drinks are a suitable temperature when given to residents, there is nothing to suggest any harm came to Mr Z.

A staff member told Mrs X that care workers referred to her father as ‘Mr Dunno’, as he was unable to respond to questions due to his dementia

30. In her complaint, Mrs X does not identify the staff member who told her about the staff using this nickname for her father. There is nothing to suggest Mrs X ever heard the staff using this name about her father or to him directly.
31. Both the Council and the Care Home accept it is totally unacceptable for staff to use nicknames, especially derogatory ones. The Council says the Care Home was unable to identify the member of staff who spoke to Mrs X about this matter. It also says that the Care Home is working with its in-house trainer to devise a training programme on professional boundaries and attitudes.

The care home failed to inform her of her rights to refer her complaint to the LGSCO.

32. Mrs X asked the Care Home for details of its complaints’ procedure. A response was provided the following day but gave only a small extract of the procedure rather than providing the full documents. The actual documents sets out how to escalate a complaint to the Council and then to the Ombudsman. This information was not provided to Mrs X. This is fault.
33. The Care Home says it displays the complaints policy and that it is available to all residents and visitors at the reception along with forms and envelopes. The Council has also recommended it provides a full copy on admission and that it is discussed as part of the admissions process.
34. While it was fault the Care Home did not provide full details, I am not persuaded Mrs X has been significantly disadvantaged as a result.

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Agreed action

35. I have identified fault in five of the issues raised. I am pleased to note the Council has made some recommendations to the Care Home in order to improve the care provided and hopefully prevent similar problems occurring again. I am not persuaded the faults identified resulted in significant injustice to Mr Z but the Council should provide a written apology to Mr Z and Mrs X. This should be provided within one month of my final decision.
36. The Council should provide us with evidence it has complied with the above actions.

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Final decision

37. I have completed my investigation with a finding of fault for the reasons explained in this statement. The Council has agreed to implement the actions I have recommended. These appropriately remedy any injustice caused by fault.

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Investigator's decision on behalf of the Ombudsman