Summary: The care provider failed to ensure a good standard of care for the late Mr X in his short stay at the care home. It acknowledges there were episodes of poor care and offers to refund a portion of the fees.

The complaint

1. Mrs X (as I shall call her) says the care provider failed her husband in many ways in the fortnight he was in respite care in Goodwins Hall. She says staff did not know how to change his convene sheath and he was often soaked with urine; his oral care was neglected; staff did not always help him eat; his medication was administered incorrectly, and medical attention was not sought promptly when he fell ill.

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The Ombudsman’s role and powers

2. 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. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

4. I considered all the information provided by Mrs X and by the care provider. Both parties had an opportunity to comment on a draft of this statement before I reached a final decision.
5. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

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What I found

Relevant law and guidance

6. 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.
7. Regulation 10 says that service users must be treated with dignity and respect.
8. Regulation 12 says that care must be provided in a safe way for service users, including the proper and safe management of medicines.
9. Regulation 13 says that service users must be safeguarded from improper treatment: “Providers and staff must take all reasonable steps to make sure that people who use services are not subjected to any form of degradation or treated in a manner that may reasonably be viewed as degrading, such as: Not providing help and aids so that people can be supported to attend to their continence needs”.
10. Regulation 14 says the hydration and nutritional needs of service users must be met.

What happened

11. Mr X went into the care home for a respite stay from 3 October to 17 October 2022. His care plan says he needed prompting and encouragement to eat and drink, and assistance with oral hygiene. He was deemed to be at medium risk of falling. He had a convene catheter in place and needed assistance from staff to manage his catheter care day and night.
12. Mrs X says she personally packed all Mr X’s medication for his stay and included a few extra packs just in case. She says she also provided a full box of 60 convene sheaths for his fortnight’s stay. She says at home she would use a maximum of two sheaths a day.
13. Mrs X says a friend visited Mr X every day while he was in the care home. She says the first time she visited she found Mr X sitting in reception without socks or a jumper and feeling cold (after that she laid out his clothes for next day herself). She says Mr X’s new toothbrush was found still in its wrapping three days after he went into the home. Mr X was seen on several occasions not wearing the convene sheath and sitting in clothes wet with urine. The friend reported that care staff did not know how to properly apply the convene sheaths so they stayed on. She also said staff were not helping Mr X at mealtimes.
14. Mrs X says there was confusion over Mr X’s registration with a temporary GP surgery and delays in prescribing and obtaining antibiotics when he had a chest infection. She also says he returned home with some packs of tablets untouched, whereas only one sleeping tablet was left when there should have been many more.
15. On 6 October Mr X had an unwitnessed fall from his chair and was found on his side in his room. The care home’s falls policy says residents who fall should be “subject to a thorough assessment for signs and symptoms of fractures and for the possibility of a spinal injury before any attempt to move them is made”. The accident report reads “full hoist used and was checked over no complaints of pain checked all observations was all in range written on vital signs chart.” The care home records show that the care staff telephoned Mr X’s daughter to let her know. The accident and incident report concludes with a note to staff to ensure Mr X was more comfortable in his room before he was left as he was trying to pick something up from the floor when he fell.
16. The care records show Mr X often refused food even when offered assistance or alternatives: on other occasions he was recorded as eating and drinking well. The notes also show occasions when Mr X refused medication. On 6 October a member of staff requested a medication review because of Mr X’s repeated refusal of his medication: however, as his stay was temporary it was decided to continue with his care as planned. The care notes record frequent episodes of the medication being offered, refused and wasted.
17. On 14 October Mr X started to feel unwell and the care home sought medical help. Mr X was prescribed antibiotics for a chest and urine infection.
18. Mrs X picked Mr X up from the home on 17 October. She says his health continued to decline over the next fortnight. He died on 31 October.

The complaint

19. On 11 November Mrs X complained to the care provider. She complained about the failure to provide proper oral hygiene; that staff were unable to manage to convene sheaths; that the incorrect amount of medications had been returned; and that staff had not encouraged Mr X to eat and drink properly.
20. The care home manager replied in December.
21. In respect of the missed medication, she said the records showed that sometimes medication had been administered late but the records did not show any missed medications. She said occasionally Mr X had pulled at his convene sheaths but the records showed up to six a day were being used and the supply ran out by 13 October. She acknowledged staff should have ordered more and apologised they had not done so.
22. The manager said there was some evidence of good practice in Mr X’s oral care but it was not consistent.
23. The manager said Mr X’s care plan clearly stated he should be assisted to eat and drink and the daily notes showed this had been done. She said she was satisfied the care staff had complied with the falls policy when Mr X had fallen from his chair.
24. In respect of Mr X becoming ill after the fall, the care home manager said Mr X had been seen by the community matron on 13 October. She said all his signs had been within a normal range but staff had contacted the surgery subsequently as they were concerned about his urine output. She said beyond the advice to encourage fluids and monitor his condition, there were no other recommendations.
25. Mrs X remained dissatisfied with the response and complained to the Ombudsman. She said the care Mr X had received was not up to the expected standard and there had been little respect for his dignity. She said on his return home from the care home the seat of his wheelchair was soaked through with urine.
26. The care home’s general manager acknowledges that staff were unfamiliar with the use of the convene sheaths and says Mr X was the first resident for some time to have had this sort of catheter. She says before admission of another resident with a convene she will arrange for staff training so all staff are confident in their use.
27. The general manager acknowledges the shortfalls in the service provided and offers the sum of £1400 in a partial refund of the £3000 fees Mrs X paid for her husband’s care.

Analysis

28. There were some shortcomings in the care and treatment of Mr X while he was resident in the home. These were principally centred on his continence care where it was clear staff were unable to use the sheaths provided and failed to seek advice or order more when the supply ran out. That resulted in a lack of dignity for Mr X and considerable distress for Mrs X.
29. There is no evidence the home failed to comply with its falls policy: the records showed staff checked him thoroughly before using the hoist as appropriate.
30. Mr X sometimes refused to eat even when he was offered alternatives but the evidence suggests the care staff adhered to the care plan in trying to encourage him to do so. However, there is evidence his oral hygiene was not always undertaken properly. The care provider says (in response to my draft decision) “we are reviewing our oral care training competencies assessment framework and induction programme to enhance our staff knowledge of the daily oral care importance”.
31. It is unclear why there was a discrepancy between the medication supplied by Mrs X and that returned by the home. However, the care notes were clearly marked when Mr X refused to take his medication.

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Agreed action

32. The care provider has offered a partial refund of fees to the sum of £1400. In my view this is a sufficient remedy for the injustice caused to Mrs X and the care provider should pay this within one month of my final decision;
33. Within one month of my final decision the care provider will also provide evidence of staff training in the use of the convene catheter.
34. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

35. I have completed this investigation on the basis that the actions of the care provider caused injustice to Mrs X, which the completion of the recommendations at paragraphs 32 and 33 will remedy.

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Investigator's decision on behalf of the Ombudsman