Summary: Mrs D complained about the oral care provided to Mrs B while she was in a care home, how medication was administered and failure to communicate with her. The care provider failed to follow its policy on oral care, failed to inform Mrs D when a tooth fell out and misled her about whether it would send the further response to her complaint. An apology, writing off some care fees, payment to Mrs D and a reminder to staff is satisfactory remedy.

The complaint

1. The complainant, Mrs B, is represented by her daughter, Mrs D. Mrs D complained the care provider:
• failed to have a process in place to ensure oral care was provided for those residents who regularly refused it;
• failed to arrange a dentist appointment or provide pain relief when Mrs B’s tooth fell out;
• failed to include in its records a report from the dentist in 2022 which recommended various measures which were therefore not in place;
• failed to consider whether Mrs B was struggling to eat due to tooth decay rather than her dementia;
• failed to tell her about the loss of Mrs B’s tooth which meant no action was taken on it for more than seven days;
• provided medication to Mrs B which made her sleepy as a means to manage her agitation when that was not appropriate;
• failed to explain what had happened when responding to her complaint; and
• misled her into believing the care provider would send her further clarification after its complaint response when the officer dealing with it knew she was leaving the organisation.
2. Mrs D says the failures meant Mrs B missed out on appropriate oral care and she (Mrs D) has experienced distress.

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The Ombudsman’s role and powers

3. 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)
4. 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)
5. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I have and have not investigated

7. I have investigated what has happened since February 2023, which is 12 months before Mrs D’s complaint to the care provider. I have not investigated any period before February 2023 as I see no reason why Mrs D could not have complained to the Ombudsman within 12 months.

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How I considered this complaint

8. As part of the investigation, I have:
• considered the complaint and Mrs D's comments;
• made enquiries of the care provider and considered the comments and documents the care provider provided.
9. Mrs D and the organisation 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

CQC regulations

10. 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) The Ombudsman considers the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
11. Care and treatment should 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)
12. 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))

The Care provider’s oral health policy (the policy)

13. The policy says oral health for people living in care homes is as important as any other personal care activity.
14. The policy says if the resident does not have capacity staff must work in the most sensitive and person centred way to support the resident with their oral care needs. If the resident declines help the staff must work together to identify the best way to offer support.
15. The policy says residents must be referred to the dentist if there are concerns with oral hygiene. It says the resident must be referred to the GP/dentist if any of problems require medical intervention.
16. The policy says teeth should be brushed twice a day.
17. The policy says the resident should be encouraged to see a dentist with the frequency of visits agreed between the resident and the dentist.
18. The policy says all aspects of mouth care that provide comfort and improve quality of life should be included in the resident’s care plan.
19. For those without capacity if they decline oral care the following should take place:
• return to the resident later;
• clearly explain the procedure and provide reassurance as well as giving positive feedback and encouragement;
• develop a routine (same time, same carers);
• carry out various actions to encourage compliance, including measures to encourage the resident to open their mouth;
• give positive feedback and encouragement at each step.
20. The policy says contact the care plan must include details for the dentist.
21. The policy says the care plan must include instructions on the support required to provide oral care to the resident if required.
22. The policy says daily notes must include information on oral care provided and any changes in condition of the mouth, gums, teeth or dentures. It also says daily notes should document any pain or signs of infection and action taken to alleviate any discomfort. It says where a resident is unable to express pain or discomfort the Abbey pain scale should be used to support pain management to measure its effectiveness.
23. The policy says any changes in a resident's oral health which has a detrimental effect on their well-being must be reported to the resident’s GP and/or dentist as soon as possible, outcomes documented and the oral health assessment re-completed.

Mrs B’s care plan

24. Mrs B’s care plan contains the following advice:
• Mrs B needs the assistance of two people with grooming and hygiene and is sometimes resistive but it is in her best interest to receive personal care and grooming daily;
• staff should assist her to coordinate dental appointments as needed;
• if Mrs B declines to brush her teeth staff should leave her and come back after 10-15 minutes and approach her in a different way;
• she needs to use a toothbrush with a small head and medium bristles and a child’s toothbrush may be easier to use;
• staff will tell her clearly and simply what they intend to do showing the toothbrush and toothpaste;
• staff will support her jaw to keep the teeth together while they clean the front of the teeth;
• staff will encourage her to open her mouth wide while they clean the inside and chewing surfaces of the teeth using gentle, circular movements and paying extra attention to the area where the tooth meets the gum;
• Mrs B would like a dental checkup every six months and staff should help her organise that appointment and tell her family.

What happened

25. Mrs B moved into Southampton Manor Care Home in 2020 (the care home).
26. On 28 October 2023 the care provider noted Mrs B's upper left tooth had broken. One of the care home’s registered nurses spoke to Mrs B who denied she was in pain. The registered nurse did not consider it necessary to seek immediate medical advice although she intended to telephone Mrs D to tell her about the broken tooth and about booking an appointment for medical advice. The care provider accepts it failed to do that.
27. Mrs D became aware of the broken tooth when she visited on 4 November. Mrs D suggested the painkillers usually administered would not be sufficient to address any issues with pain. The care home made an appointment with the dentist on 6 November and contacted the GP on 7 November to get a prescription for a stronger painkiller.
28. Mrs D took Mrs B to the dentist appointment on 10 November. However, the appointment was unsuccessful as Mrs B refused to open her mouth.
29. The care provider took further advice from the GP on 12 November as Mrs B was drowsy. The GP advised the care provider to administer paracetamol rather than the stronger painkiller as that could cause drowsiness.
30. Mrs B sadly passed away later in November. The coroner, in his report, noted the state of Mrs B’s oral hygiene and dental health was poor. The coroner said it was difficult to reliably comment on whether that was causing Mrs B pain or whether it impacted on Mrs B’s ability to eat as those assessments were better made during life. He went on to record poor oral intake due to the effects of advanced dementia may impact on an individual’s ability to maintain good oral health.
31. Mrs D put in a complaint which the care provider responded to on 1 March 2024. Mrs D raised concerns about that complaint response and posed further questions. The officer that responded to the complaint asked Mrs D to give her a further 14 days to respond to it. When Mrs D chased a response on 22 March it became clear the officer in question had left the care provider’s employment. The care provider said the response it had already provided was the end of the process and directed Mrs D to the Ombudsman.
32. Partly as a response to the learning from this complaint the care provider has taken the following actions:
• reinforced communication protocols to staff to ensure they tell family members when an issue arises;
• introduced a detailed handover form to complete when a staff member leaves, with a handover meeting date scheduled once a resignation is received;
• carried out a review of the internal system to record complaints with the intention to introduce a new workflow step where the operations director is alerted to an escalated concern;
• introduced a partnership with at home dental service to support residents in the home with dental appointments and some treatments. This is a private arrangement with the service offering free oral health checks to all residents;
• the oral health policy has been updated to reflect the new oral health competency that all clinical and care staff are required to complete.

Analysis

33. Mrs D says the care provider did not have a process in place to ensure oral care was provided to those residents who regularly refused it. Having considered the documentary records I am satisfied the care provider has a process in place and did so at the time of the events complained of. As part of that process if a resident refuses oral care the expectation is care staff will return later to make a further attempt. I am therefore satisfied the care provider has a process in place.
34. Having considered the oral care records for Mrs B though, I am not satisfied the care provider followed its policy and the recommendations in Mrs B’s care plan. That is because the evidence I have seen satisfies me there were more than 40 occasions between February 2023 and November 2023 when Mrs B refused oral care, particularly in the evenings. On almost all those occasions there is no evidence care staff returned to Mrs B later to try to encourage her to accept oral care. Failure to follow the care provider’s procedure and what was recorded in Mrs B’s care plan is fault. That meant Mrs B missed out on oral care on more than 40 occasions in the evening between February and November 2023, although she did receive oral care in the mornings.
35. I note the coroner said there was evidence of poor oral hygiene and dental health and Mrs B’s case. As I say in paragraph 22, the care provider’s oral health policy makes clear daily records should include reference to any changes in the condition of the resident’s mouth, gums and teeth. I have seen no evidence in any of the daily care records provided to me to suggest the care provider followed that policy, although it did complete an oral health assessment in March 2023 which did not identify any concerns. As there is no reference to issues with the condition of Mrs B’s gums or teeth in the daily care records after that I cannot be satisfied those matters were checked and that is fault.
36. Mrs D says the care provider failed to arrange a dentist appointment for Mrs B or provide her with pain relief when her tooth fell out in October 2023.
37. Under the care provider’s oral health policy it is expected to report any changes in oral health that have a detrimental effect on well-being to the GP and/or dentist as soon as possible. The care provider is also expected to complete another oral health assessment. The care provider completed another oral health assessment. However, it is clear the care provider did not seek advice from the GP or dentist for several days and only then after Mrs D asked the care provider to act. Given Mrs B had a broken tooth I would have expected the care provider to follow its policy and contact the GP or dentist at least on the day following the tooth being broken. Failure to do that is fault and potentially means Mrs B had to suffer pain for longer than she should have.
38. I am also concerned Mrs B had not seen a dentist since 2022 given her care plan says dental appointments should take place every six months. Failure to follow what was set out in the care plan is fault.
39. Mrs D says the care provider failed to keep on its records a report from the dentist in 2022. Mrs D says that is important because the report recommended various measures and because the report was not on file it means those measures were not put into place.
40. The care provider accepts when it moved from one computer system to another it failed to transfer the dentist report from 2022. That is fault. However, the evidence I have seen satisfies me the care plan the care provider completed set out in detail the actions needed to encourage Mrs B to accept oral care. I consider it likely those actions were based on the dentist report in 2022 given they are detailed and contain instructions for care staff. That satisfies me that even though the dentist report was not on file the care staff knew about its contents and the advice. I therefore could not say failure to keep the report on file meant the measures were not in place. As I said earlier though, there is some evidence of failure to follow the policy in relation to oral care.
41. Mrs D says the care provider failed to consider whether her mother was struggling to eat due to tooth decay rather than dementia. I understand why Mrs D would be concerned. However, while the coroner’s report identified poor oral care it also confirmed dementia can affect a person’s oral intake and ability to maintain good oral health. The coroner also made clear assessing whether a person’s ability to eat is affected by poor oral care is an assessment best made whilst they are alive. In those circumstances, while I understand Mrs D’s concern, I could not say it was fault for the care provider to decide Mrs B was struggling to eat due to dementia.
42. Mrs D says the care provider failed to tell her when Mrs B lost her tooth which meant the care provider took no action for more than seven days. As I said earlier, there was a delay seeking medical attention following the loss of the tooth. It is also clear the care provider failed to contact Mrs D to tell her about the loss of the tooth. That is despite the fact Mrs B’s care plan says the home should contact Mrs D if Mrs B needs to go to the dentist. Failure to contact Mrs D when Mrs B lost her tooth is fault.
43. Mrs D says the care provider was providing medication at the end of Mrs B’s life which made her sleepy when it was not necessary. The evidence I have seen satisfies me all the medication the care provider administered to Mrs B was prescribed by the doctor. I cannot criticise the care provider for administering medication which the GP had prescribed.
44. Mrs D says the care provider failed to provide any answers when responding to her complaint or identify any measures to improve provision in the home. Having considered the care provider’s complaint response, I am satisfied the care provider gave Mrs D a detailed response. I am also satisfied in that complaint response the care provider told Mrs B about action it had taken to address the issues that had arisen. I therefore have no grounds to criticise the care provider in relation to the complaint response letter.
45. I am aware though following that response Mrs D contacted the care provider again to outline the areas where she felt further information was required. I recognise Mrs D had completed the care provider’ complaints procedure and therefore there was no option to request a further response. However, in this case the person that wrote the complaint response told Mrs B she would address the additional questions and asked for a further 14 days to respond. It is not surprising in those circumstances Mrs D expected a further response. It is clear though the care provider did not provide that response because the officer in question left the organisation before that 14 day period expired. Given the care provider had committed to provide a further response failure to do so is fault. I consider an apology satisfactory remedy, alongside the steps the care provider has already taken for dealing with further complaint concerns.
46. I now have to consider what injustice has resulted from the fault I have identified in this statement. It is clear the main issue here is with the oral care provided to Mrs B and failure to follow policy and keep Mrs D informed. It is not normally possible for the Ombudsman to remedy any injustice to the person receiving care when they have died. In this case though I am aware there are outstanding care fees which the care provider is seeking payment of from Mrs B’s estate. I cannot recommend the care provider write off all those charges given Mrs B received care while she was in the care home. I consider it would be appropriate though for the care provider to reduce the amount outstanding by £1,000 to reflect the failure to follow its policy and provide adequate oral care to Mrs B on all occasions between February and November 2023. The care provider has agreed to that.
47. It is clear to me Mrs D has experienced some distress and is left with some uncertainty about whether the issues that arose in this case could have been avoided. To remedy that distress and uncertainty I recommend the care provider apologise to Mrs D and pay her £500. I also recommend the care provider send a reminder to care staff about what the oral health policy says for those who refuse oral care and the circumstances in which contact with the GP/dentist is required. I make no further recommendation for any procedural remedies given the action the care provider has taken, as outlined in paragraph 32.

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Recommended action

48. Within one month of my decision the care provider should:
• apologise to Mrs D for the distress and uncertainty she experienced due to the faults identified in this decision. The care provider may want to refer to the Ombudsman’s updated guidance on remedies, which sets out the standards we expect apologies to meet;
• pay Mrs D £500;
• deduct £1,000 from the care fees outstanding;
• send a reminder to care staff about what the oral health policy says for those who refuse oral care and for the circumstances when seeking advice from the GP/dentist is appropriate.

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Final decision

49. I have completed my investigation and uphold the complaint.

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Investigator's decision on behalf of the Ombudsman