Summary: There is no evidence to show Mrs X was provided with poor care in a residential care home.

The complaint

1. Mr X complains about the quality of care provided to his late wife in a residential care home.

Back to top

The Ombudsman’s role and powers

2. 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. If they have caused a significant injustice or that could cause injustice to others in future we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
3. It is our decision whether to start, and when to end an investigation into something the law allows us to investigate. (Local Government Act 1974, sections 24A(6) and 34B(8), as amended)

Back to top

How I considered this complaint

4. I have:

• considered the written complaint and supporting information provided by Mr X;
• considered correspondence exchanged between Mr X and the care home, including the care home’s response to the complaint;
• considered the care home’s responses to enquiries made by this office;
• taken account of relevant legislation;
• offered Mr X and the care home an opportunity to comment on a draft of this document.

Back to top

What I found

Relevant legislation

5. 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. The following standards are relevant to how the care home managed Mrs X’s care.

Deprivation of Liberty

6. The Deprivation of Liberty Safeguards provide legal protection for individuals who lack mental capacity to consent to care or treatment and live in a care home, hospital or supported living accommodation.
7. There are two types of authorisation. Urgent authorisations are made by the managing authority of the care home, for seven days, pending application for a standard authorisation. Standard authorisations are made by the Council.
8. On application, the supervisory body must carry out assessments of the six relevant criteria: age, mental health, mental capacity, best interests, eligibility and ‘no refusals’ requirements. A minimum of two assessors, usually including a social worker or care worker, sometimes a psychiatrist or other medical person, must complete the six assessments. They should do so within 21 days, or, where an urgent authorisation has been given, before the urgent authorisation expires.

Background

9. Mrs X had a diagnosis of Alzheimer’s disease. Prior to moving into the care home, she lived at home, with Mr X being her sole carer. Mr X found caring increasingly difficult which culminated in Mrs X needing an urgent placement in a residential care home.
10. At that time, there was only one suitable placement available. Mr X viewed the care home and requested a placement for Mrs X. The care home completed a pre-admission assessment of Mrs X. The pre-admission document records Mrs X to be directing aggressive behaviour towards Mr X, and she often resisted support with personal care. Mr X reported the involvement of mental health professionals but said a formal assessment had not yet been completed. Mrs X was reported to be mobile, but at risk of falls.
11. Mrs X went into the care home on 21 June 2023. The care home completed a temporary care plan the same day. The document gives a brief overview of Mrs X’s day-to-day care needs. It records she was disorientated to time and place, could be disinhibited, and remove her clothing, and could at times be agitated and exhibit physical aggression. It was expected she would be unsettled and may wander, looking for her husband.
12. A risk assessment and falls risk assessment were also completed. Amongst other support, Mrs X was deemed to require 30-minute checks to ensure her safety. A fall sensor mat was also installed.
13. Over the following days Mr X found Mrs X to be sometimes unwashed, unkempt and had what he describes as extensive bruising to her body. On some visits Mrs X was in a state of undress in communal areas.
14. Care records show Mrs X to be extremely agitated and distressed at times. She was often reluctant to accept care and could be physically aggressive towards care staff. On occasions of acute distress Mrs X would attack Mr X and care staff had to intervene.
15. Mrs X damaged fixtures and fittings in her bedroom, and her physical strength was such that she was able to lift her bed and place it sidewards against the wall. Her behaviour resulted in bruising, some of which was extensive, and some minor injuries. Mrs X would drop to the floor, bang against windows and punch and kick doors/exits in an attempt to leave the building. She had numerous falls and was reluctant to accept support from care staff. She frequently removed her clothing and refused to allow care staff to re-dress her.
16. Mr X believed Mrs X had been assaulted by a member of the care staff, he informed the police and the Council’s safeguarding team. He also commissioned the services of a solicitor.
17. The care home contacted Mrs X’s GP to report the bruising on Mrs X and of Mr X’s belief that his wife had been assaulted. The GP confirmed one of Mrs X’s prescribed medications made her very prone to bruising.
18. The care home contacted the local community mental health team on 26 June 2023 to discuss Mrs X’s “…behaviours, falls and agitation towards staff”. The mental health team confirmed a referral had been received on 16 June 2023, about Mrs X directing aggressive behaviour towards Mr X; five days before Mrs X went into the care home.
19. The care home introduced behaviour charts as an observation tool to aid understanding of the triggers/causes of Mrs X’s behaviour. Body mapping charts were also introduced. Such charts pinpoint and record any visible injuries or marks on a person’s body and monitor skin conditions. Incident forms were completed as necessary.
20. The police responded to the allegations made by Mr X. A police officer visited the care home to undertake a welfare check of Mrs X and met with the manager to discuss the situation. The carer alleged to have assaulted Mrs X was interviewed at the police station. Following this the police deemed no further action to be necessary and closed the case. Mr X was informed about this.
21. Mr X, the solicitor and Mrs X’s GP visited the home and met with the care home manager. No further action was deemed necessary by the GP or the solicitor.
22. The Council made initial safeguarding enquiries, following which it ceased the investigation. The social worker involved with Mrs X communicated the findings and outcome to Mr X.
23. On 1 July 2023, the care home contacted social services to ask that it find an alternative placement for Mrs X, and that she likely required an EMI (Elderly Mentally infirm) placement.
24. The care home applied to the Council for a Deprivation of Liberty (DOLS) authorisation. A DOLS assessor visited Mrs X on 6 July 2023. The assessor had access to Mrs X’s care plan, care records, and medication charts. The assessor reported Mrs X to be experiencing delirium and a deterioration in her presentation; thought to be due to a change of environment. Mrs X was wandering, agitated, and refusing care. The assessor recommended input from the NHS mental health team. An urgent NHS nursing assessment was also requested to aid the identification of an alternative placement more suited to Mrs X’s needs. The assessor recommended the mental health team consider provision of 1-1 support whilst assessments were completed. The DOLS authorisation is dated 12 July 2023.
25. Mr X says it was suggested to him that Mrs X may need to be admitted to hospital for assessment of her mental health. He says despite requests by social services, a formal mental health assessment from the NHS was not forthcoming.
26. A Consultant Psychiatrist visited Mrs X in the care home on 19 July 2023 to assess her condition. Mr X was present and discussed his concerns about Mrs X’s wellbeing. The psychiatrist contacted Mr X five days later to say Mrs X should remain at the care home. Mr X was unhappy with this decision as he believed Mrs X should be admitted to hospital for assessment.
27. Mrs X had numerous falls on concurrent days in August 2023. She was taken by ambulance for assessment in hospital and returned the same day. The following day, she was taken to hospital by ambulance again, and was admitted. Mr X decided he did not wish her to return to the care home. Mrs X was subsequently discharged from hospital to a different care setting.

The care home’s response to Mr X’s concerns

28. The care home formally investigated Mr X’s concerns. I have had sight of the investigation report dated 10 July 2023. The report is detailed and comprehensive and addresses all the issues raised. The investigator had sight of all relevant care records, photographs of bruising to Mrs X, and information provided by the NHS mental health team and Mrs X’s GP. The investigator concluded “…it is highly likely the bruising sustained by [Mrs X] was caused by her presenting behaviours and there is no evidence to suggest that any abuse has occurred”.
29. A meeting was held at the care home on 23 August 2023 to discuss the findings of the investigation. Mr X attended along with the owner & manager of the care home, a social worker from social services and a CPN from the mental health team. The outcome of the Council’s safeguarding investigation was also discussed.
30. Mr X was dissatisfied with the outcome. He submitted a formal complaint to the care home on 19 December 2023. The care home responded on 10 January 2024. The author of the letter addressed Mr X’s concerns/allegations and re-iterated the outcome of the independent investigation, the safeguarding investigation and the findings and conclusions of the police and mental health team.

Analysis

31. It is clear from the information I have seen that Mrs X’s illness had a profound effect on her, which must have been very distressing for both her and Mr X. Mrs X went into the care home at very short notice. The care home completed an initial assessment of Mrs X and decided it could meet her needs, but it would not have been possible to understand the level of her needs or her mental distress in any depth at this point.
32. The care home completed a temporary care plan. Risk assessments and other monitoring documents were completed appropriately. The care home’s daily care records set out the difficulties Mrs X was experiencing and recorded and mapped bruising/injuries caused by her own actions. Such was the nature and degree of Mrs X’s illness, she presented with behaviour that was very challenging for carers to manage.
33. All professionals involved with Mrs X agreed her presentation and physical state to be a consequence of her illness, and not due to poor care.
34. The care home acted properly in seeking a DOLS authorisation to protect Mrs X from harm. I note the assessor recommended urgent mental health input and that Mrs X required a different care setting more suited to her needs.
35. Whilst I appreciate the situation must have been very difficult for Mr X. There is no evidence which suggests Mrs X was provided with poor care.

Back to top

Final decision

36. There is no evidence to show Mrs X was provided with poor care in a residential care home.
37. It is on this basis; the complaint will be closed.

Back to top

Investigator's decision on behalf of the Ombudsman