Summary: Ms X complains that, despite her complaints, the Council’s care provider, Gorton Parks Care Home, continues to fail to meet her mother’s care needs. This includes not supporting her to eat properly, leaving her unwashed and in unclean clothes, and leaving her to use the rubbish bin in her room as a toilet. The Council accepts Gorton Parks needs to improve its record keeping. It has also offered to arrange a meeting with Ms X and Gorton Parks to enable her to raise concerns when they arise so Gorton Parks can address them. The Council also needs to work with Gorton Parks to make sure it improves the support it provides for Ms X’s mother.

The complaint

1. The complainant, whom I shall refer to as Ms X, complains that, despite her complaints, the Council’s care provider, Gorton Parks Care Home (Gorton Parks), continues to fail to meet her mother’s care needs. This includes not supporting her to eat properly, leaving her unwashed and in unclean clothes, leaving her to use the rubbish bin in her room as a toilet.

Back to top

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. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, sections 30(1B) and 34H(i), as amended)
4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)

Back to top

How I considered this complaint

5. I have:
• considered the complaint and the documents provided by Ms X;
• discussed the complaint with Ms X;
• considered the comments and documents the Council has provided in response to my enquiries;
• considered the Ombudsman’s guidance on remedies; and
• invited comments on a draft of this statement from Ms X, the care provider and the Council, for me to consider before making my final decision.

Back to top

What I found

What happened

6. Ms X’s mother, Ms Y, has lived in Gorton Parks since 2021. She has dementia. Ms X visits her mother most days, often early in the morning.
7. Gorton Parks’ care plan for Ms Y says she:
• wraps food in tissues or hides food in her handbag;
• needs her food and fluid intake monitoring due to poor intake;
• has a BMI of 14.9, indicating she is underweight;
• prefers her own company and does not get involved in group activities;
• needs staff to check on her every hour;
• can use the toilet on her own. She has a commode in her room to use at night. She wears continence pads for her dignity but may refuse support to change the pad, which can leave her skin vulnerable. She will not tell staff if she has been incontinent or has used the commode. She has a history of going to the toilet in bins;
• to contact family if Ms Y does not settle after providing reassurance.
8. The care plan contains contradictory information about Ms Y’s risk of malnutrition. Her MUST (a standard tool for measuring the risk of malnutrition) score is 4, which means she is at high risk. But there are references to her being at low risk. It is also not clear whether Gorton Parks is consistently monitoring Ms Y’s food and fluid intake.
9. Ms X complained to the Council in July 2023. When the Council replied to her complaint later in July, it said:
• It apologised because a member of staff at Gorton Parks (who no longer works there) had shouted at Ms X. It said this was unacceptable behaviour.
• Gorton Parks had accepted there were incidents of unacceptable poor practice, including a member of staff speaking to Ms X in a rude and unprofessional manner, and had apologised.
• It held an initial safeguarding meeting in September 2022, after Ms X raised concerns about her mother’s care, which resulted in Gorton Parks and the Council agreeing to address her concerns. At a meeting in October to review progress, Ms X confirmed there had been some improvement and Gorton Parks had been contacting her. Gorton Parks agreed there had been some communication problems. Ms X declined the offer of further mediation, so the Council closed its enquiries into the safeguarding concerns.
• Of the three showers on Ms Y’s unit at Gorton Parks, the one closest to her room was out of order due to a leak. Ms Y had a full body wash, shower or bath on 22 out of 28 days. On some days she declined help with personal care.
• As Ms X visited her mother in the morning before she had got up, there may be a smell of urine in her room. When the Council had visited on two dates in July, her room had been clean, tidy and did not smell. There were no records of faeces being found in Ms Y’s room, or other items which should not have been disposed of.
• Ms X should sign in and out when visiting her mother.
• Ms X should alert staff if the toilets or her mother’s commode needed cleaning.
• The record showed Ms Y’s pressure areas were intact. No barrier creams had been prescribed. Ms X had reported her mother being constipated, which resulted in medication being prescribed.
• Gorton Parks denied failing to call Ms X if staff could not get Ms Y to settle in the evenings. There was evidence it had done this in July. However, the Council would ask Gorton Parks to review the arrangement, so everyone was clear about the expectations.
• Gorton Parks’ records showed Ms Y sometimes engaged in activities, but did not always want to do so. It would recommend Gorton Parks did more to support Ms Y to engage in activities.
• Ms X would help her mother with personal care and changing clothes because she visited before she had got up. When the Council visited on a day Ms X had not visited, Ms Y had been helped to wash and dress before breakfast. On another visit, Ms Y had taken herself to bed during the day.
• It would ask Gorton Parks to record when staff helped Ms Y dress in fresh clothing.
• Gorton Parks had accepted misplacing Ms Y’s clothes and offered to pay for replacements, an offer which remained open.
• Gorton Parks’ records for June said Ms Y had received all her medication, most of which was in liquid form, apart from one tablet. It could not explain where a tablet may have come from which Ms X said she found in her mother’s room.
• The decline in Ms Y’s appetite was a common impact of dementia, so she had been prescribed fortified drinks to supplement her diet. Ms Y would eat some of the food Ms X brought for her, but not necessarily all of it. Either way, staff would wash the containers before returning them to Ms X.
• It would ask Gorton Parks to apologise for the way it had spoken to Mr X when she brought in fortified drinks for her mother. However, it explained that Gorton Parks would only administer medication “prescribed directly in collaboration with the GP”.
• Gorton Parks had no record of food being found in Ms Y’s room or of this being reported to staff. Ms Y had lost 4.1 kg over the past year, so the dietician had recommended continuing with food supplements.
• It was sorry Ms X felt her mother would suffer because she had reported concerns. It was open to Ms X to use Gorton Parks’ complaints procedure, contact Ms Y’s social worker or make a complaint to the Council.
10. The Council did not address Ms X’s concern that her mother was using the rubbish bin in her room as a toilet every day.
11. As Ms X was not satisfied with the Council’s response, she took her complaint to the next stage of its complaints procedure. When the Council replied in September, it said:
• It would ask for the person who had spoken to Ms X in a rude and unprofessional manner to apologise personally to her.
• It had had no reason to question the accuracy of Gorton Parks’ records relating to Ms Y’s hygiene. It suggested Ms X raise any further concerns with Gorton Parks when they arose, so it could record them and identify a solution if it became a common occurrence.
• It did not accept Ms X’s claim that the only reason her mother’s room was clean and did not smell was because Ms X cleaned it every day, as there was no problem when it visited on a day Ms X had not visited.
• Ms Y could use her commode independently but did not tell staff when it needed emptying, so it would only be emptied when staff discovered it themselves.
• Ms Y’s records for skin integrity for the past year, including February 2023 when Ms X said she had taken a photograph, identified no problems.
• Gorton Parks’ records for 17 and 18 August showed staff changed Ms Y’s continence pad regularly.
• An assessment had identified Ms Y’s ability to respond to sensory level activities. Staff at Gorton Parks were working to identify such activities for her.
• Gorton Parks’ records showed that on three dates identified by Ms X, her mother had declined the offer of help getting changed. However, she had accepted help changing her continence pad.
• Ms X had not recently reported clothing and other items missing. Previously, when clothing had been reported missing, another family member had taken them to wash them.
• It accepted a tablet (medicine) had been found on the floor of her mother’s room. Her records had been updated so staff made sure Ms Y swallowed her medication.
• Gorton Parks said if Ms X had found food she brought in for her mother in its fridge, it was either because it had not yet been given to her or because she had eaten some but not all of it. It understood Ms X was no longer taking food in for her mother.
• Ms X had not provided any photos of food in her mother’s room, so it could not investigate her claim that this had happened further.
• Gorton Parks was now recording when staff changed Ms Y’s clothes.
• It offered to respond if Ms X wanted further explanations, but did not agree to her request for a meeting.
12. The Council says staff at Gorton Parks check on Ms Y every hour. It says, when necessary, they change her pad, empty her commode and clean the bin. It says during November to December 2023, there is only one record of Ms X telling staff her mother had used the bin in her room as the toilet.
13. I asked the Council to respond to Ms X’s claims made in her diary of problems she has encountered at Gorton Parks. The Council points out that Ms X has identified issues on many dates, which are not reflected in Gorton Parks’ records. It suggests Ms X may not have raised her concerns at the time. It says it encourages people to raise issues as they arise, so they can be properly investigated. About Ms X’s other concerns, the Council says:
• Gorton Parks’ records show Ms Y does not always accept help with personal care, including refusing to change into nightwear.
• Ms X often visits her mother before she has got up and provides personal care before staff have had the opportunity to do so.
• The rug Ms X said had gone missing was still in her mother’s room.
• Staff would only apply moisturiser which had been prescribed for Ms Y.
• Ms Y can drink independently. She may have taken a fortified drink to her room and put it down, as she was active and walked about. Staff encouraged her to maintain her independence.
• Ms X was not entitled to use the disabled parking bay. If she saw others using the parking bay who were not displaying a blue badge, she should report it to Gorton Parks.
• The Council would work with Gorton Parks to improve the accuracy of its care notes, which sometimes contained conflicting timings.
14. The Council has offered to arrange a meeting with Ms X and Gorton Parks to agree a way in which she can report her concerns in a timely manner, so Gorton Parks can address them when they arise.
15. Ms X accepts her mother does not want to move from Gorton Parks.
16. Gorton Parks keeps electronic records of the support provided to Ms Y. The Council has provided the records for November and December 2023. Gorton Parks does not consistently record Ms X’s visits. Sometimes staff record the support Ms X has provided for her mother. But sometimes they simply say Ms X visited in the morning. On 25 December the records say Ms X took her mother home for lunch and brought her back around 17.30. Staff continued to record “Checked, was awake, was content” while Ms Y was out with her daughter. On 20 December staff did not record checking on Ms Y between 07.00 and 11.00.
17. Ms X also keeps a record of her visits and the problems she has witnessed. During November and December 2023 she recorded problems on most days. They included Ms Y often urinating in the rubbish bin, leaving her in soiled continence pads, not changing her clothes, not cleaning the commode, leaving her unwashed and food in her drawers.

Is there evidence of fault by the Council which caused injustice?

18. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall. Regulation 17 requires care providers to maintain an accurate, complete and contemporaneous record of the care provided for each service user.
19. The Council accepts Gorton Parks needs to improve its record keeping. The failure to maintain accurate records is a potential breach of Regulation 17. The fact that staff can record checking on someone who is not in the home, means its records are unreliable and we cannot be sure they reflect an accurate record of the support being provided for Ms Y. Gorton Parks does not always record Ms X’s visits or the support she is providing for her mother. It should record this consistently, as it is important to know who is providing support for Ms Y.
20. Ms Y’s care plan contains conflicting information about her risk from malnutrition. It is not clear whether Gorton Parks is doing all it should to reduce the risks to Ms Y. The Council needs to make sure Gorton Parks reviews her care plan and that it is taking the action it needs to take to manage the risk to Ms Y. For instance, I would expect someone at high risk of malnutrition to have their food and fluid intake recorded and monitored.
21. Gorton Parks is aware that Ms Y has a tendency to take food to her room and hide it among her possessions. It is also aware that she uses the bin in her room as a toilet. But there is nothing in its records to suggest staff check for these things. It seems unlikely Ms X would so often find her mother has urinated in the bin if staff were checking for this and cleaning up.
22. The faults I have identified are faults for which the Council is accountable (see paragraph 4 above).

Back to top

Agreed action

23. I recommended the Council:
• Within four weeks writes to Ms X offering to arrange a meeting with Gorton Parks so they can discuss ways to improve the support provided to Ms Y and enable Ms X to report her concerns as and when they arise.
• Regardless of whether Ms X takes up this offer, within eight weeks works with Gorton Parks to improve the support it provides for Ms Y, including improving its record keeping to ensure its records are accurate and:
1. Records reflect the time actions are taken;
2. Routine checks are actually carried out;
3. Staff record Ms X’s visits and the support she provides for her mother;
4. More focused checks are carried out (e.g. around hiding food, using the bin as a toilet).
24. The Council has agreed to do this. It should provide us with evidence it has complied with the above actions.
25. Under the terms of our Memorandum of Understanding and information sharing protocol with CQC, I will send it a copy of my final decision statement.

Back to top

Final decision

26. I have completed my investigation on the basis there has been fault causing injustice which requires a remedy.

Back to top

Investigator's decision on behalf of the Ombudsman