Summary: We upheld complaints about personal care, cleaning, medication administration and support at meals. The Care Provider will apologise and make a symbolic payment to Mr X to reflect avoidable distress. Appropriate service improvements are already in hand.

The complaint

1. Mr X complained about the Care Provider’s care of his relative Mr Y in Birkdale Tower Lodge (the Care Home) which the Care Provider owns and runs. He complained about:
1. Lack of support at meals
2. Poor conditions in Mr Y’s room
3. Two medication incidents
4. Two assaults involving another resident getting into his room, slapping him and throwing an item at him.
5. Not giving personal hygiene care, especially when Mr Y refused
6. The circumstances leading to Mr Y receiving notice to leave.
2. Mr X said this caused him and Mr Y avoidable distress.

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What I have and have not investigated

3. I have investigated complaints (a) to (e). I haven’t investigated complaint (f) because the Care Provider hasn’t had a reasonable chance to respond. Mr X needs to us its internal complaint procedure first.
4. Mr X complained to us in October 2022. I have investigated Mr Y’s care between October 2021 and October 2022. Complaints about things which happened before October 2021 are late (see paragraph six) and there is no good reason to investigate them. And Mr X confirmed most of the issues he is complaining about happened during the time I am investigating.

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The Ombudsman’s role and powers

5. The law says we cannot normally investigate a complaint unless we are satisfied the care provider knows about the complaint and has had an opportunity to investigate and reply. However, we may decide to investigate if we consider it would be unreasonable to notify the care provider of the complaint and give it an opportunity to investigate and reply (Local Government Act 1974, section 26(5))
6. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)
7. 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)
8. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
9. 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

10. I considered Mr X’s complaint, the Care Provider’s response, the local authority's safeguarding records and care records set out in this statement. I discussed the complaint with Mr X.
11. Mr X and the Care Provider had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Relevant law and guidance

12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) We consider the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
13. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
14. Regulation 14 of the 2014 Regulations says the nutrition and hydration needs of residents must be met. They must receive suitable nutritious food and fluid to sustain life and good health, with support to eat and drink if needed.
15. Regulation 12 of the 2014 Regulations says care must be provided in a safe way including assessing risks to the safety of people using the service and doing all that is reasonably practicable to mitigate risks. Guidance explains medicines should be given accurately and in line with the prescriber’s instructions and at suitable times to ensure the person is not placed at risk. Staff must follow policies and procedures about managing medicines and these should address supply and ordering, storage, preparation and dispensing, administration, disposal and recording.
16. Guidance from the National Institute for Health and Care Excellence (NICE): Managing Medicines in Care Homes explains:
• A medication error may be a safeguarding issue
• Care home staff should find out the root cause of medicine-related incidents.

What happened

17. Mr Y has dementia and some chronic physical health problems. The Care Home is registered to provide personal care, but not nursing care.

Mr Y’s care plans

18. I have summarised relevant information in Mr Y’s care plans, which staff reviewed monthly and updated where necessary:
• Mr Y’s mobility declined and he was cared for in bed as he could not weight bear and he did not like using the hoist.
• He could be verbally aggressive and offensive towards care workers and shouted noisily. A doctor had increased his medication to deal with this.
• The behaviour care plan set out triggers for Mr Y’s verbal aggression. Staff needed to talk to him face to face and not rush him. He needed time to calm down and reassurance with one-to-one staff support. Speaking to his daughter and a gin and tonic also calmed him. Senior staff needed to give him regular pain relief medicine, so discomfort was less likely during personal care.
• Care workers gave him bed baths and a chiropodist did foot care. He did not like to be rushed during personal care as this caused him to become agitated. Staff needed to be patient. He needed two staff for personal care, and four staff to reposition him in bed using a slide sheet. (Mr Y was a large man)
• The nutrition care plan set out Mr Y’s preferences for food and drink. He liked to have meals and drinks in his room. Staff were to ensure he was sitting in a comfortable upright position. The care plan said Mr Y did not need any assistance with eating and drinking, other than provision of food and fluid. He was overweight. Staff could not weigh him anymore as he did not like to be hoisted so they could not use the scales.
• The behaviour plan said Mr Y liked speaking to people and became frustrated when they needed to leave the room. Staff needed to reassure him, offer him a drink, look at him when with him and give pain relief as sometimes personal care caused him discomfort and leave his door open so he can see other people.
• Staff put his tablets in his hand to take them with water. He could say when he needed pain relief. He was given the wrong dose of one tablet on one occasion (half what it should have been). Staff called the GP for advice and no harm was reported.
19. Staff spoke with Mr Y’s relatives in July and September and explained they could not meet Mr Y’s needs and he needed nursing care. Mr X selected care plans he wanted to read and is noted to have been happy with the content and to have agreed nothing needed changing.

Daily care records

20. Staff recorded the care and support they provided using an electronic record. I have looked at records for three months.
21. For most days, the daily records indicate Mr Y had a wash, hairbrush, denture care, change of clothes and had his feet checked every day. On a few occasions he refused some parts of the care routine like having his hair brushed. There is no record of any hair washing taking place.
22. There is no record of any personal hygiene care on 28 or 29 August.

Incident reports

23. The Care Home’s reports of two incidents said:
• In August, a resident went into Mr Y’s room as she was agitated that he was shouting loudly. She slapped him. Staff intervened and calmed the situation. He was unharmed.
• In November, the same resident threw an item at him and threated to suffocate him. She was moved to another floor.

The Care Provider’s response to the complaints

24. Mr X complained to the Care Provider in September about the same things he has raised with us. He also contacted us in October, but we told him to wait for the Care Provider’s response before we would investigate. The Care Provider responded in November saying:
• Staff could not lock doors as this would be restricting movement. Staff locked vacant rooms and did their best to distract residents from going into Mr Y’s room
• There was one incident where another resident went into Mr Y’s room and slapped him as he was shouting. The Council was made aware of this incident but did not pursue it
• Mr Y’s room was nearest the lounge and staff tried to observe it and prevent other residents from entering
• A senior care worker received an informal warning about leaving medication on the side. They would have retraining. Medication errors were monitored and reported to the local authority’s safeguarding team and to the GP to check if there was any harm
• Mr Y resisted personal care. It would expect staff to walk away and return and attempt again. Staff had received training in dementia care and how to approach people who may resist care
• It was sorry for the poor standard of cleanliness in the room and had addressed this with the housekeeping team.
• It wasn’t acceptable for Mr Y to be left in an uncomfortable position to eat meaning his plate was balanced on his chest. The care plan would be amended to advise that food needed to be cut up, Mr Y needed to be upright and his side table at an accessible height.
• It was sorry for the delay in responding to the complaint.
25. Shortly after receiving the Care Provider’s response, Mr X emailed a manager to say staff had told him about a second incident where the same resident came into Mr Y’s room and threw a can at him and was holding a plastic apron. He said he was not happy with the complaint response. He also reported Mr Y was covered in food when his sister visited a few days earlier.

Safeguarding enquiry report

26. The Care Home reported matters to the local safeguarding team.
27. The local authority completed a safeguarding enquiry into the matters Mr X has raised with us. It concluded risk assessments had not been updated to reflect Mr Y’s changing needs. The safeguarding officer reported the case to the Council’s commissioning and contract quality team for monitoring checks. They recommended training for staff in record keeping, managing challenging behaviour and medicine administration.

Information from the Care Provider

28. The Care Provider told me staff tried to redirect the resident but this was not possible on occasions and she was then moved to a different floor of the home. It also said Mr Y had been assessed by the district nurse as needing nursing care and a number of nursing homes had assessed him but declined to offer him a place. The Care Provider told me this was a concern which it had reported to the CQC as it was not registered to provide nursing care.
29. I have seen the Care Home’s cleaning records. The cleaner has signed to say they cleaned each of the bedrooms on Mr Y’s floor, including his. The cleaning tasks included dusting, sweeping the floor, mopping, cleaning the bathroom, dusting and cleaning surfaces and emptying bins and replacing liners. A deep clean of each room happened each month.

Findings

(a) Lack of support at meals

30. The Care Provider accepted Mr Y should have been sitting in a comfortable upright position and should have a side table correctly positioned. And it accepted he needed his food cutting up and said in the complaint response that it would ensure the care plan was amended. Yet Mr Y’s care plan was not amended to reflect that food should be cut up. This means care was not in line with Regulations 9 or 14 and this was fault. It would have caused Mr Y avoidable distress and relatives were also distressed by witnessing or hearing reports of Mr Y receiving poor care and on one occasion seeing him in a dishevelled state.

(b) Poor conditions in Mr Y’s room

31. The Care Provider has apologised for poor conditions in Mr Y’s room. The cleaning records I have seen indicate the room was cleaned every day, but of course rooms can get untidy and dirty between cleans and we would expect any mess to be cleared up as soon as possible. The apology is an appropriate response for any distress caused.

(c) Two medication incidents

32. Care was not in line with Regulations 12 or 9. The senior care worker should have checked they were giving the right dose and should not have left tablets on the side because Mr Y needed his tablets placed in his hand. There is no evidence to suggest any harm to Mr Y.
33. I am satisfied with the Care Provider’s action when it became aware of the incidents. For the under dose, it liaised with the GP who confirmed there would be no harm. And with regard to the placing of tablets on the side, the staff member received disciplinary action and retraining. This is in line with the NICE guidance for care homes set out in paragraph 16.

(d) Two assaults involving another resident getting into his room, slapping him and throwing an item at him.

34. The Care Home is not staffed to provide one to one care and it could not lock Mr Y’s room as this would be disproportionate and isolating for him in terms of contact because he was in bed all the time. Care homes need to take appropriate steps to minimise risks, but they cannot prevent every incident occurring. Provisionally, I am satisfied with the Care Provider’s action following the first incident because staff intervened and redirected the resident. Mr Y’s room was next to the lounge to allow staff to keep an eye on who was entering the room. After the second incident, my view is the Care Provider took appropriate steps to remove the risk by moving the resident. This was an appropriate response and there is no fault.

(e) Not giving personal hygiene care, especially when Mr Y refused

35. The records indicate Mr Y received most personal hygiene care on most days apart from two in August. There is no record his hair was washed. This was fault. Care was not in line with Regulation 9. This would have caused Mr Y avoidable distress and also his relatives would have been upset to see his hair looking unkempt.

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Agreed action

36. The Care Provider has apologised to Mr X for the distress caused. And it has taken action against the staff member including retraining.
37. Within one month of this statement, the Care Provider will make a symbolic payment of £250 to reflect the frustration and distress caused to Mr Y by receiving poor nutritional and personal care. This can be offset against any outstanding bill.
38. The local authority’s contract team will visit the Care Home to complete quality monitoring checks. This is an appropriate action to minimise the risk of recurrence and there is therefore no need for me to recommend any further action to improve the service.
39. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

40. We uphold complaints about personal care, cleaning, medication administration and support at meal times. The Care Provider will apologise and make a symbolic payment to Mr X to reflect avoidable distress. Appropriate service improvements are already in hand.
41. 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.
42. I completed the investigation.

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Investigator's decision on behalf of the Ombudsman