Summary: Miss B complains about the care provided to her grandmother at a care home. She says there was poor hygiene, there were inaccurate records, her grandmother’s nutritional needs were not met and the Home did not fully respond to her complaint. We have found that there was poor record keeping in certain areas, there was an incident of poor hygiene in the room and the Home did not address all the complaints. The Council has agreed to apologise, pay a small financial remedy and carry out a service improvement.

The complaint

1. Miss B complains on behalf of her grandmother, Mrs C, who has died. The complaint relates to Riverside Nursing Home (Care UK) in Hyde, Cheshire. Miss B complains about the quality of the care provided to Mrs C, the Home’s record keeping and communication.

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 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)
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, sections 24A(1)(A) and 25(7), as amended).
4. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

5. 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)

Back to top

What I have and have not investigated

6. I have investigated the complaints about the Home. Miss B has also complained about the Continuing Health Care (CHC) assessment which determined whether Mrs C was eligible for NHS funding. I have not investigated that complaint because the actions of the NHS are not within the remit of the LGSCO. The Parliamentary and Health Ombudsman investigates complaints about the NHS.
7. In any event, there is a separate appeals process for CHC funding which Miss B is pursuing.

Back to top

How I considered this complaint

8. I have discussed the complaint with Miss B. I have considered the information that she and the Council have sent and the relevant law, guidance and policies.

Back to top

What I found

Law, guidance and policies

Care Quality Commission and fundamental standards

9. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards which says:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• The care and treatment must be provided in a safe way for service users. This includes the proper and safe management of medicines (regulation 12).
• Any complaint must be investigated and necessary and appropriate action must be taken in response to any failure identified (regulation 16).
• The Home must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17)

What happened

11. Mrs C was an older woman who needed additional care and support who lived at Riverside Nursing Home. Mrs C moved into the Home on 16 January 2023.

Miss B’s complaint – August and September 2023

12. Miss B complained to the Home in August and September 2023 and said:
• Mrs C’s room was dirty on 8 July 2023 and on 22 August 2023 and her bedding was soiled with urine and dried blood. Mrs C had gone into hospital on 15 August 2023 and the room had not been cleaned since then.
• On 8 July 2023 Mrs C’s toe-nail had ripped across the nail bed as her toe nails had not been kept short.
• She sent photos on 20 August which showed that Mrs C’s toes were bandaged and said this showed that the Home failed to provide appropriate foot care to Mrs C.
• Mrs C was often in soiled clothing, including knickers and bottoms soaked with urine and faeces. She questioned whether Mrs C was encouraged to maintain personal hygiene.
• Mrs C’s care plan said Mrs C needed to be encouraged to eat and drink and given fortified drinks, but she questioned whether the Home was providing this. She said that when she visited Mrs C for 3 or more hours, the care worker did not knock on the door and there were untouched sandwiches which had been left for hours.

The Home’s response – September 2023

13. The Home responded to Miss B’s complaint and said:
• Mrs C was seen by the podiatrist on 12 June 2023 and the podiatrist visited every 6 to 8 weeks. The podiatrist was due to visit Mrs C on 14 August 2023 but Mrs C had not been well enough for the visit, so this had been cancelled.
• Mrs C had an accident on 29 July 2023 when a mug fell on her foot which caused an injury. A dressing was applied, a wound care plan put in place and a body map completed.
• The Home apologised for the state of the room on 22 August 2023 when Mrs C was in hospital.

Miss B’s complaint – January 2024

14. Miss B complained in January 2024 and said:
• She did not accept that the podiatrist had carried out sufficient treatment.
• She did not accept that Mrs C injured her toes from a broken cup. She said Mrs C’s cup was plastic and Mrs C did not walk barefoot. She questioned why the Home did not inform the family of the incident.
• The state of the room on 22 August 2023 was not a one-off occurrence.

The Home’s response – March 2024

15. The Home replied and said:
• Mrs C was seen by a chiropodist on 12 June 2023 and her toe-nails were cut and dry dressings applied to her feet. These dressings were changed every 5 to 7 days and were applied for protection, not to heal a wound.
• On 29 July 2023 Mrs C cut her toe on a broken cup. The Home said that it called Mrs C’s family on 31 January 2023 (I presume this is an error and the Home meant 31 July) as Mrs C was having chest pains and ‘they would have mentioned the toes.’
• The Home upheld the complaint about the condition of Mrs C’s room on 22 August 2023 and apologised for this.

Miss B’s complaint

16. Miss B obtained the Home’s records for Mrs C and made a further complaint and said:
• Mrs C should have been weighed weekly but this did not happen.
• The Home’s assessment contained contradictions about Mrs C’s mobility needs, teeth, choking risk and glasses. Miss B said this indicated that the Home did not carry out the assessments correctly or recorded them properly and that the care was inadequate.
17. Mrs C pointed out the following contradictions in the Home’s assessment of Mrs C. The assessment said:
• Mrs C used a wheelchair, walked unaided, did not need assistance and needed full assistance.
• Mrs C had her own teeth, wore full dentures and part dentures.
• Mrs C had never been prescribed antibiotics which was not correct as she had been prescribed antibiotics on 6 and 29 June 2023 and 10 July 2023.
• Mrs C did not have glasses. This was not correct as Mrs C had glasses.
• Mrs C was assessed on 19 August 2023, which was not true as she was in hospital on that day.

The Home’s response – June 2024

18. The Home responded and said:
• Mrs C was at high risk of malnutrition. She was weighed regularly, but not weekly. The care plan said that she should be weighed weekly and ‘reduce this measure as per her risk assessment.’ The Home said it did so and, when a weight loss was recorded, Mrs C was weighed weekly.
• Mrs C was reviewed by a dietitian three times and the last review was in April 2023. She was seen by the nurse on 18 July 2023 and the GP on 20 July 2023 and no concerns were raised about her weight.
• It admitted that the Home should have chased the dietitian for all professionals to have input in Mrs C’s care but said the Home followed up with the community nurse and the GP and no concerns were raised regarding Mrs C’s weight.
• The mobility assessments were correct as there were changes in Mrs C’s mobility. She was able to walk and would use her Zimmer frame. A wheelchair was available for longer distances.
• There were errors in the records on Mrs C’s teeth. Mrs C had her own teeth but some teeth were decayed or broken. It apologised for the error but said this did not affect Mrs as she was able to eat and there was no choking risk.
• There was an error in the recording risk as Mrs C did receive antibiotics so it was wrong to say she never received antibiotics.
• Mrs did not have glasses on her inventory and the Home had never known her to wear glasses. But it accepted that there was an error in the documents and that Mrs C may well have needed glasses.
• Mrs C was assessed by the DoLS assessor on 15 August 2023. The assessment said her care need was reviewed and said ‘remains in hospital’.

Analysis

19. I have summarised and grouped my findings from the records and my analysis under separate complaint headings for clarity.

Footcare

20. The Home has provided evidence that Mrs C was seen by a podiatrist on 12 June 2023.
21. The Home said Mrs C had bandages on her feet because of an incident that happened on 29 July 2023 but Miss B questioned whether this incident happened.
22. I have read the incident reports of 29 July 2023. The report noted that Mrs C had called for help during the night at 4:15 am. The nurse went to the room and noticed a mug broken into two pieces and Mrs C had sustained a cut to her right big toe. A photograph was taken, the wound dressed and a care plan put in place. The nurse said the cut was superficial and Mrs C was able to walk normally. So, overall, I find no fault in the way the Home responded to the injury to the foot and its record keeping.
23. The incident form noted: ‘Have the next of kin been informed? – Unit to confirm.’ I could not find any evidence that the Home informed the family of the injury at the time so there was fault in that respect.

Nutrition

24. The Home has not fully responded to Miss B’s complaint about the nutrition so there is some fault in that respect.
25. I note the following from the records that the Home has sent. The dietitian prepared a nutrition care plan for Mrs C on 21 February 23 which said:
• The Home should monitor Mrs C via food charts and regular weighing.
• Mrs C was prescribed nutrition supplement 1 which was to be provided 3 times a day and supplement 2 which was provided 2 times a day.
• The Home should offer high calorie milky drinks and high calorie snacks 2 to 3 times a day and document this on Mrs C’s food charts.
• The Home should fortify meals to make them more nutritionally dense.
• If Mrs C’s weight dropped below 36.3 kg, she should be referred back to the dietitian.
26. The Home’s care plan for nutrition said:
• Mrs C was at high risk of malnutrition.
• Staff should encourage and prompt Mrs C to eat and try again if she refused.
• Staff should offer Mrs C high calorie and high protein snacks throughout the day.
• Staff should keep diet and fluid charts for Mrs C and record all intake.
• Staff should weigh Mrs C weekly, reducing to monthly as risk assessed.
27. I have read Mrs C’s daily records and nutrition charts for two weeks in March 2023. These showed that the staff offered Mrs C food four times a day, breakfast, lunch, teatime and supper. I could not find evidence that the staff offered snacks throughout the day in addition to the four meal-times, apart from the prescribed nutrition supplements.
28. The medication administration records (MAR) charts showed that Mrs C was given nutrition supplements 1 and 2 in line with the prescription. There were only a few times that Mrs C did not take the supplement so I find no fault in the way the Home administered the prescribed nutrition supplements.
29. I have also checked whether Mrs C was weighed regularly and was weighed weekly, if she lost weight.
30. The Home sent me Mrs C’s weight charts from 8 March 2023 to 6 July 2023. Mrs C was weighed on 4 June 2023 and it was noted that she had lost weight but she was not weighed again until 19 June 2023. Mrs C was weighed on 25 June 2023 and had lost further weight but was not weighed until 6 July 2023 (40.5 kg).
31. So the Home did not always weigh Mrs C weekly when she had lost weight and there was some fault in that respect. However, I note that Mrs C’s weight did not fall below the re-referral trigger weight set by the dietitian which was 36.3 kg. Her weight mostly increased between March and May but then decreased again.

Hygiene

32. Miss B complained about the hygiene in the room on two occasions and complained about Mrs C’s personal hygiene so I have considered both aspects. The Home has not really responded to the complaint about Mrs C’s personal care but it should have done.
33. In terms of personal hygiene, Mrs C’s care plan said:
• Mrs C was not able to shower or take a bath independently.
• She required the assistance of two staff for washing and dressing.
• Due to paranoid thoughts, she could be suspicious and resistant to personal care at times.
• She was reported to refuse to change her clothes or to have a wash or shower at times so needed prompting and encouraging.
• If Mrs C was resistant, staff to come back after half an hour or an hour.
• If Mrs C continued to resist personal care, staff should report to the nurse and document accordingly.
• Mrs C was continent of urine and faeces and was independently mobile to go to the toilet, but may ask staff where the toilet was. Mrs C did not wear incontinence pads by had them in case of accidents.
34. I have checked the daily records for three weeks in March and one week in July. Unfortunately, the records were not detailed enough to say whether Mrs C was offered or provided assistance with personal care (washing and dressing) every day. Assistance with personal care was recorded on some days, but not on other days.
35. It is impossible to say whether this was because the personal care was not provided or because it was not recorded but either way there was fault. I accept that there may have been days when Mrs C refused personal but the offer and refusal should have been recorded. Good record keeping is essential as, without the records, it is impossible to say whether something has happened or not.
36. In terms of continence care, I note that Mrs C could go to the toilet independently and this was recorded on most days. There were no records that Mrs C had an accident but I accept that this may have happened.
37. In terms of Mrs C’s personal hygiene on 8 July, the date when Miss B visited Mrs C, the records said Mrs C was assisted with personal care in the morning and personal care assistance was offered throughout the day so there was no fault in that respect.
38. The Home has not responded to the complaint that the room was not clean on 8 July 2023 so it is difficult for me to comment. But the Home should have properly responded to the complaint so its failure to do so is fault.
39. The Home has upheld the complaint about the state of Mrs C’s room on 22 August 2023 and I agree this was fault.

Assessments document

40. The Home carries out a monthly review of a resident’s assessments, including risk assessments and care plan and this is done by ticking various boxes on an electronic system. The document is called ‘Assessments’. The aim, I presume, is to determine whether the care plan has to be changed in any way.
41. The document identifies over 20 ‘choking risk indicators’. One of the indicators is whether a person has a urinary tract infection or has been prescribed antibiotics. The Home ticked the box ‘never’ as an answer but, as Miss B pointed out, Mrs C had had urinary tract infections and a chest infection which required antibiotic treatment. The Home upheld the complaint that the occurrence of the urinary tract infection and the prescription of antibiotic were not properly recorded and I agree this was fault.
42. Miss B also said that the document contained contradictory information about Mrs C’s mobility as it said Mrs C walked unaided, used a wheelchair and ranged from not needing help to requiring full assistance.
43. I have looked at Mrs C’s mobility as it was set out in her care plan. Mrs C was able to walk for short distances using a Zimmer frame but she often forgot to use the frame. She was at high risk of falls and was reliant on staff to keep her room safe from obstacles. She had an alert mat to alert staff when she was mobilising. The review of the plan in June 2023 noted that Mrs C needed a wheelchair for long distances.
44. So Mrs C’s mobility needs were complex and it was difficult to reflect this complexity in the ‘Assessment’ document. This is why the document may appear contradictory but overall I find no fault in this respect.
45. The Home has also upheld the complaint that the ‘Assessment’ document was incorrect in terms of Mrs C’s teeth. Mrs C had some unhealthy and broken/decayed teeth so it was not correct to say that her teeth were healthy and I agree this was fault.
46. The Home also upheld the complaint that the records said that Mrs C did not have poor vision, even though she needed glasses. I agree this was fault.
47. Mrs C also said that the ‘Assessments’ document said the Home had assessed Mrs C on 19 August 2023 when Mrs C was in hospital. The record shows that the wound care section of Mrs C’s care plan was reviewed on 18 August 2023. The document says ‘remains in hospital’ which was the extent of the ‘review’ so there is no real fault here.

Injustice

48. It is difficult to say what level of injustice Mrs C has suffered because of the fault I have found. A lot of the fault related to poor record keeping and if a record is not kept, it not always possible to say whether the care was not provided or whether it was not recorded. That is why good record keeping is essential.
49. The aim of the Ombudsman’s remedy is to put the person who has suffered the injustice into the position they would have been if the fault had not occurred. Sadly, as Mrs C has died, the Ombudsman cannot remedy any injustice she has suffered. However, I accept that Miss B has also suffered an injustice as she suffered distress and was concerned about the care that Mrs C received. In cases such as this one, where the injustice is distress, the Ombudsman can offer a small symbolic sum as a financial remedy and I recommend the Council pays Miss B £150.

Home’s response

50. The Home provided the following response to the decision: ‘We agree with the Ombudsman's findings in regard to reminding the Home of good record keeping. Since the complaint in 2023 there has been new management in the Home who has concentrated on care planning. To rectify the findings in the complaint the Home has had care planning training, 1-1 sessions, regular care plan audits and reviews with the staff team responsible for care planning. These actions will remain ongoing. The Home Manager will also share the final findings with the team around lessons learnt.’

Back to top

Agreed action

51. The Council has agreed to take the following actions within one month of the final decision. It will:
• Apologise to Miss B in writing for the fault.
• Pay Miss B £150.
• Ask the Home to remind staff of the importance of good record keeping.

Back to top

Final decision

52. I have completed my investigation and found fault by the Council. The Council has agreed the remedy to address the injustice.

Investigator’s decision on behalf of the Ombudsman

Back to top

Investigator's decision on behalf of the Ombudsman