Summary: Ms Y did not receive oral care in line with her care plan and her family were given inaccurate information that changes to one of her medicines had been made, when the GP had not made changes. This was fault causing her family avoidable distress and the Council should apologise. There was fault in Ms Y’s personal care, but action has already been taken to remedy the injustice. We do not uphold complaints about actions taken after a fall, one-to-one care, support to go to bed or actions taken in response to weight loss.

The complaint

1. Ms X complained for her relative Ms Y about Ms Y’s care in Meadowbrook Care Home (the Care Home) commissioned by Shropshire Council (the Council). Ms X complained about:
1. Poor cleanliness in Ms Y’s room;
2. Poor personal hygiene: not washing Ms Y’s hair and not ensuring her face and clothing were cleaned up after meals;
3. Failure to notice Ms Y had a serious injury after a fall;
4. Failure to be open and transparent about the fall and failing to communicate with the family about Ms Y’s care needs;
5. Poor oral hygiene;
6. Inappropriate administration of medicine at night;
7. Failure to give one-to-one care;
8. Not supporting Ms Y to go to bed at night (allowing her to fall asleep in her chair); and
9. Failure to take action in response to weight loss.
2. Ms X said as a result of the failings in Ms Y’s care, Ms Y’s condition has declined and her quality of life is reduced.

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The Ombudsman’s role and powers

3. 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)
4. The Care Home provided services on behalf of the Council in discharging its legal duty under the Care Act 2014 to meet Ms Y’s eligible social care needs. Any fault by the Care Home is fault by the Council.
5. 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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
6. 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)
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

8. I considered the complaint to us and the Council and Care Home’s complaint responses. I discussed the complaint with Ms X.
9. Ms X, the Care Home and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Relevant law and guidance

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations) set out the requirements for safety and quality in care provision. When investigating complaints about council-funded care placements, the Ombudsman considers the Regulations when determining complaints about poor standards of care. I have summarized the Regulations relevant to this complaint below:
1. Care and treatment needs 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. (Regulation 9)
2. A care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents. (Regulation 12(i))
3. A care provider needs to keep accurate, complete and contemporaneous records of care and treatment and decisions taken about care and treatment (Regulation 17)
4. 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. (Regulation 18)
5. The duty of candour requires care providers to be open and transparent when things have gone wrong. As soon as the care provider becomes aware of a safety incident, it must tell the person or their relative; provide reasonable support, advise them of any further enquiries, keep a written record and apologise. (Regulation 20)
6. 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 (Regulation 14)
11. The Care Home’s post fall protocol describes what staff are to do on finding a resident has fallen:
• Ensure the safety of the resident.
• Call for assistance of other staff.
• Assess breathing.
• Assess for signs of injury – like head injury, deformity, lacerations.
• Call emergency services if emergency treatment required.
• Staff can move a resident after fall and decide which piece of equipment is best to use to move the person from the floor safely.

What happened

Background

12. Ms Y was admitted to hospital in April 2023 after her mental health declined. She was diagnosed with dementia. A social worker assessed her as eligible for social care after completing an assessment. The outcome was Ms Y’s needs could be met in a care home and the Council commissioned a placement for her.

The Care Home’s care records and care plans

13. Ms Y went into the Care Home in June 2023. She took regular medicine including Medicine A at night.
14. Ms Y’s social worker and a member of staff at the care home spoke about one-to-one care and the view was she did not need this.
15. The Care Home drew up care plans describing Ms Y’s needs and preferences and how to meet them. Ms Y’s care plan was amended to include that Ms Y would often sit herself on the floor and will get up on her own when she wanted to. She walked independently, would pace about and could grab and throw objects when agitated.
16. The care plans said:
• Ms Y would decline personal care and staff were to give her space and offer again.
• Ms Y was to have a shower twice a week, she needed help with oral care, twice a day and she liked to look smart.
• Ms Y had poor posture and she needed staff to tell her to sit up straight on her chair, with a pillow at her back to help with her posture.
• Ms Y walked independently with close supervision and no walking aid. She needed hourly checks when in her room.
• She ate independently with prompting. She was at low risk of malnutrition and her weight was within a normal range.
• Ms Y was a very high falls risk. Her room needed to be kept free of clutter and clean. The plan was updated with a record of several falls, witnessed and unwitnessed. She had a sensor mat in her room that went off when she got out of bed.

Review of the care and support plan

17. A social worker, Ms X and another relative met with staff at the Care Home at the start of August. The social worker completed a review of Ms Y’s care and support plan. Ms X and the other relative raised concerns about the Care Home’s service including:
• Ms Y’s clothes being jumbled and disorganised. It was not clear if they were being returned from the laundry this way or if another resident was accessing the room. Senior staff would monitor the situation and discuss it with care staff of the problem continued.
• Ms Y had food on her when they visited and this was not acceptable. Staff were to ensure her appearance was checked after meals.
• Ms Y sometimes declined a shower, although offered one two to three times a week. Staff would offer a shower more frequently.
• Sometimes Ms Y wasn’t falling, she would lower herself to the floor; her posture was variable. There was a sensor in her room to manage the risk. This alerted staff when Ms Y got out of bed.
• She had lost 3kg since admission; her weight was still within a healthy range and the plan was to fortify her diet and monitor her weight. If this did not work, a referral to the dietician would be made.
• The GP would be contacted about changing Medicine A to the day.
• There was a discussion about risk factors around falling. Ms X asked for one-to-one support. The professionals’ view was that there were enough staff on the unit to manage the present risk by maintaining Ms Y within eyesight.

Records from the Care Home about Ms Y’s health, weight, medication and a fall.

18. A member of staff at the care home noted that they had contacted the GP on 4 August about changing Ms Y’s medication to night and about referring her to a speech and language therapist. Staff reminded the GP two weeks later.
19. The Care Home weighed Ms Y each month. Her weight stayed the same for the first three weeks. It dropped from just under 58 kg at the end of June to just under 52 kg in the middle of August including a drop of 4 kg in July. Staff started to weigh her weekly in August following a review of her nutritional risk assessment.
20. On 14 August, a note on the care plan said Ms Y had lost 1.4 kg since the previous week and had been referred to the dietician (by the GP on 7 or 9 August). She was to be offered fortified drinks and assisted with meals. Staff were to continue to record her food and fluid intake and to give her finger food if she could not use cutlery.
21. The Care Home referred Ms Y to a speech and language therapist on 16 August noting she had lost 2 kg in the last month.
22. Ms Y had a fall on the evening of 16 August. The records state:
• She was in the dining room; kitchen staff opened the door when it happened. A member of staff opened the door to walk out and knocked into Ms Y.
• She was getting uncomfortable on the floor and so staff used the hoist to move her.
• Staff called 999. Ms Y was complaining of pain in her knee, could move the leg but could not bend it. Her observations were normal and she had not hit her head.
• She was moved to bed as staff could not leave her on the floor in the dining room.
• She had pain relief and regular checks by nursing staff; she was washed in bed as she could not bear weight. Her right knee seemed swollen.
• Staff spoke to Ms Y’s relative on the phone and explained what happened. They updated the relative when the ambulance arrived and spoke to her again the following day.
• Staff called 999 again later in the evening about the delay in the ambulance arriving. They were advised an ambulance would be sent as soon as one was available.
• The ambulance arrived in the morning and took her to hospital.
• The Care Home sent a notification to the Care Quality Commission and spoke to Ms Y’s social worker.
23. At hospital, Ms Y was diagnosed with a broken hip.
24. The Care Home’s incident report of the fall said there were discussions about minimising the chance of recurrence. The Care Home put keypad locks on the dining room door so residents could not go in the dining room without staff being there and ordered a new door with a glass pane in it.
25. The Care Home’s personal care records indicate Ms Y had a wash every day and a shower or bath once or twice a week. Staff cleaned her teeth once a day.
26. The cleaning records indicate Ms Y’s bedroom was cleaned every day.

The Care Home and Council’s responses to the complaint

27. The Care Home and Council’s responses to the complaint said:
• It was sorry they had to tidy Ms Y’s room. She was active at night and would rearrange her room. This was no excuse and staff should have tidied it.
• It was also sorry Ms Y had food on her face and clothes. Staff would check this after meals.
• Ms Y’s posture was stooped. Staff were aware and placed pillows to support her posture. Changing her position caused her to become aggressive and she would sometimes resume her original position after support.
• The fall behind the kitchen door was reported to the CQC and to the Council’s safeguarding team. A new door had been ordered. Staff did not notice any shortening of her leg and the only concern was her knee. The Care Home anticipated a delay by the paramedics and so decided to move her using a sling hoist. And the floor was cold. She was transferred to bed, observed and given pain relief.
• The medicine was changed to daytime on 7 August after Ms X raised concerns.
• Mx Y’s weight was monitored weekly and there were referrals to the dietician and speech and language therapist.
• Ms Y did not need one-to-one care. She was given support to eat at meals.
28. The Council’s quality monitoring (QM) team visited the Care Home after the complaint response and carried out checks of rooms, checked the kitchen door had been changed and followed up that the actions agreed had been completed. The QM Team noted the CQC had visited and had no concerns.

Findings

Poor cleanliness in Ms Y’s room

29. The records indicate Ms Y’s room was cleaned every day, so I do not uphold a complaint about cleanliness.
30. The Care Home and Council accept the room became messy on occasion; it was unclear whether this was due to staff, another resident or to Ms Y herself. The outcome of the care plan review was care staff were to monitor the situation and ensure the room was tidy. I am satisfied with the Care Home’s response to the issue. There is no significant injustice requiring a remedy.

Poor personal hygiene: not washing Ms Y’s hair and not ensuring her face and clothing were cleaned up after meals

31. The Care Home and Council accept personal care was not in line with accepted standards and apologised and noted following the review that Ms Y would be offered a shower more often. It was not in line with Regulation 9 and so I uphold this complaint.
32. I am satisfied with the Care Home and Council’s actions when the issue was raised in a care plan review meeting (to ensure in future that care staff provided personal care after meals). There is no injustice requiring a remedy.

Failure to notice Ms Y had a serious injury after a fall

33. I do not uphold this complaint. Care staff assessed Ms Y for injuries and called emergency services when she was observed to be in pain in her knee and was not weight bearing. This is in line with the organisation’s procedures on managing a resident after a fall. Ms Y was moved from the floor using a hoist. This is also in line with procedures. It was appropriate to transfer Ms Y as there was an unknown wait for an ambulance and she was uncomfortable on the floor. Ms X was monitored for pain and observations taken. In summary: care was in line with Regulations 9 and 12.

Failure to be open and transparent about the fall and failing to communicate with the family about Ms Y’s care needs

34. The records show care staff liaised with Ms Y’s relatives appropriately after the fall and in line with the duty of candour (Regulation 20). There is no evidence care staff failed to be open about what happened.

Poor oral hygiene

35. The records indicate Ms X only had oral care once a day when her care plan said this should be offered twice a day. Care was not in line with the care plan or Regulation 9 and this is fault.

Inappropriate administration of medicine at night

36. The hospital prescribed Medicine A to be taken at night and the Care Home administered it in line with the instructions. A care home cannot just change the timing of medicine. It needs to liaise with the prescriber or the person’s GP.
37. The Care Home contacted the GP on 4 August on the same day as the review meeting where changing Medicine A’s timing was discussed. The GP did not respond. We have no power to make findings against the GP. The Care Home should have reminded the GP within a reasonable timeframe. It did not do so until 14 August which was a failure to work proactively with health care professionals and a failure to deliver care in line with Regulation 12. The injustice to Ms Y is not clear.
38. The complaint correspondence said Medicine A was changed to be given in the morning. This was not correct. The records indicate the GP had not changed the instruction. Giving inaccurate information was fault causing avoidable confusion.

Failure to give one-to-one care

39. I do not uphold this complaint. The Care Home and Council considered this and decided one to one care was not necessary. I have no grounds to question that decision.

Not supporting Ms Y to go to bed at night (allowing her to fall asleep in her chair)

40. There is no information in the Care Home’s case records about this. The complaint records indicate Ms Y was mobile and awake at night, often walking around. The records also indicate that interfering with Ms Y’s position too much caused her to become aggressive. It is therefore going to be a matter of carers’ judgement at the time as to whether or not to support her to move to her bed or remain in a chair. I do not uphold this complaint as it would appear to have been Ms Y’s preference. There is no fault or injustice.

Failure to take action in response to weight loss.

41. The records indicate the Care Home acted in line with Regulations 9, 12 and 18 by reviewing Ms X’s nutritional care plan, increasing support with eating at mealtimes, increasing her weight monitoring from monthly to weekly and referring her to a speech and language therapist and dietician. I do not uphold this complaint.

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Agreed action

42. 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 Care Home, I have made recommendations to the Council.
43. Ms X has already received an apology through the internal complaint procedure for some of the complaints she has raised with us. However, I have found fault and injustice on additional matters.
44. Within one month of my final decision, the Council will apologise for the following:
• Giving incorrect information that Medicine A had been changed to be given in the morning when it had not and for not contacting the GP to remind them to deal with the request to change the time.
• Not providing oral care in line with the care plan.

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Final decision

45. Ms Y did not receive oral care in line with her care plan and her family were given inaccurate information that changes to one of her medicines had been made, when the GP had not made changes. This was fault causing her family avoidable distress and the Council should apologise. There was fault in Ms Y’s personal care, but action has already been taken to remedy the injustice. We do not uphold complaints about actions taken after a fall, one-to-one care, support to go to bed or actions taken in response to weight loss.
46. I completed the investigation.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman