Summary: Mrs W complains about the care provided to her father, Mr Y, during the time he was resident at Nelson Lodge care home. The home has already upheld some parts of the complaint. In our view, the home also failed to properly assess and manage Mr Y’s risks, and did not act upon guidance given by medical professionals about the management of an ongoing skin condition. The remedy already offered by the home is appropriate and we do not recommend anything further for Mr Y. However, the home will acknowledge the uncertainty caused to Mrs W with a symbolic payment of £250.

The complaint

1. Mrs W complains about the care provided to her father, Mr Y, during the time he was resident at ‘Nelson Lodge’, which I will refer to as ‘the home’. In particular, she complains the home:
1. did not move Mr Y into the non-dementia part of the care home despite this being the agreed plan;
2. failed to provide Mr Y with adequate support and personal care around shaving and changing from dirty clothes;
3. did not ensure Mr Y received adequate treatment to maintain his leg bandages;
4. did not ensure Mr Y’s room was properly cleaned and maintained;
5. did not properly assess and manage Mr Y’s risks around falling and did not do enough to prevent or minimise his falls; and
6. did not ensure Mr Y was able to participate in social activities and did not always ensure he was able to watch TV in his room.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C) If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
3. When considering complaints, we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
4. 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)

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How I considered this complaint

5. I considered evidence provided by Mrs W and the care home as well as relevant law, policy and guidance.
6. Mrs W and the home had an opportunity to comment on my draft decision. I considered their comments before making a final decision.
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

What should have happened

8. 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.
9. Regulation 12 aims to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Care providers must assess the risks to people's health and safety during any care or treatment and act to mitigate risks. The guidance on regulation 12 says:
• Providers must do all that is reasonably practicable to mitigate risks. They should follow good practice guidance and must adopt control measures to make sure the risk is as low as is reasonably possible. They should review methods and measures and amended them to address changing practice.
• Risk assessments relating to the health, safety and welfare of people using services must be completed and reviewed regularly by people with the qualifications, skills, competence and experience to do so.
• Providers should use risk assessments about the health, safety and welfare of people using their service to make required adjustments. These adjustments may be to premises, equipment, staff training, processes, and practices and can affect any aspect of care and treatment.

Summary of key events relevant to the complaint

10. Mr Y moved into Nelson Lodge in September 2023. Prior to this, Mr Y lived independently at home and with very little support. Mr Y’s care plan describes him as a very independent person.
11. When he moved into the home Mr Y presented with confusion and the home and Mrs W queried a possible diagnosis of dementia. During his time at the home Mr Y did not receive a formal diagnosis.
12. Mr Y moved out of the home in May 2024 after Mrs W raised several concerns about Mr Y’s care, the most significant one being about the inability of his legs to heal from a bacterial infection called cellulitis.

Complaint a)

13. Mrs W complained that, despite Mr Y’s dementia being in the very early stages, the home placed him into its dementia unit. Mrs W says she understood the home planned to move Mr Y to the non-dementia side once a room became available. Mrs W says the home did not move Mr Y despite her requests.
14. Mrs W says Mr Y experienced injustice from this decision because he deteriorated physically and mentally from not interacting with other like-minded residents. She says this is because those in the dementia unit had more advanced dementia.
15. Mrs W also complained that a resident in a room opposite to Mr Y would sometimes wander into Mr Y’s room naked. This meant that Mr Y often had to keep his bedroom door locked from the inside which added to his isolation. During a conversation between the local authority and Mrs W regarding a deprivation of liberty safeguard (DoLS) on 13 February 2023 she relayed concerns about the other resident. The DoLS form recorded:

“’We discussed how this could be managed and considered whether a safety gate at his door would allow the door to remain open and limit access to others. This would need to be considered by the home would need to risk assess this step”

16. In response to this point, the home says its pre-admission assessment concluded that Mr Y had extra support needs due to his presentation and the possibility of having undiagnosed dementia. The home felt that, due to Mr Y’s behaviours, he would be better supported within the dementia unit.
17. Whilst the home has provided an explanation of its considerations, it has not provided any contemporaneous evidence to show it made those assessments at the time. Furthermore, the home did not provide any evidence to show how it kept Mr Y’s placement under review following any changes to his behaviours.
18. In my view, this was relevant because Mrs W said Mr Y’s presentation fluctuated especially at times when he experienced confusion from a Urinary Tract Infection (UTI). Due to the lack of any assessment on this point, we cannot reach a finding on the balance of probabilities about this part of Mrs W’s complaint. This has created uncertainty for Mrs W which the home will provide a symbolic remedy for.

Complaint b)

19. Mrs W regularly visited Mr Y at the home. She complained that Mr Y often presented as unclean, unshaven and wearing dirty clothes and dentures.
20. Mr Y’s care plan says he is an independent man who will wash, dress and shower himself but will need the support of one staff member to prompt him. It says that Mr Y likes to shower and get changed before breakfast and prefers to shave daily.
21. Regarding his oral care, the care plan says that Mr Y wears dentures and has a few of his own teeth. It says that Mr Y is independent and that it is important he maintains his own oral care for as long as possible. The care plan goes on to say, “staff to document when [Mr Y] has brushed his teeth”.
22. The records show Mr Y declined personal care on 24 occasions in December, March, April and May. We asked the home if it consulted family members at times when Mr Y refused personal care. This may have been beneficial to discuss ways in which to encourage Mr Y. In response to our enquiries the home explained that the refusals of personal care were usually for short periods of no longer than three to four days. The home felt it was possible to manage Mr Y’s personal care because his refusals were not persistent.
23. Having reviewed the records provided to us, there are no notes for care delivered in the months of January and February. For the remaining records, these show that Mr Y refused personal care on multiple occasions. There is evidence of one period in March 2024 when Mr Y persistently refused a wash or shower on six consecutive days. Other than for one occasion on 30 December 2023, it is not clear whether staff returned later in the day to further prompt and offer personal care.
24. Mr Y’s care plan also makes clear that he prefers to shave every day. The care plan says that Mr Y wanted to maintain his independence and liked to have a razor in his bedroom for shaving. The personal care records do not consistently show whether staff prompted Mr Y with shaving or whether Mr Y shaved himself. The records also fail to consistently document Mr Y’s oral care. It is therefore not clear whether those important elements of Mr Y’s personal care were consistently carried out in line with his assessed needs. This fault caused uncertainty.

Complaint c)

25. During his time at the home, Mr Y had cellulitis in both legs. Mrs W complained the home did not properly maintain Mr Y’s leg bandages which often rolled down. She says this slowed down the healing process.
26. On 26 September 2023 the home recorded that Mr Y’s right leg was warm to the touch, swollen and presented with a blistering rash. The home sent photographs to the GP. The GP visited the next day to prescribe antibiotics.
27. The District Nurse (DN) visited on 6 October 2023 to check Mr Y’s legs and request blood tests. On 14 November 2023 staff at the home noted they checked Mr Y’s legs, and his right shin was weeping and dressings applied. On 17 December 2023 the home noted a worsening in both of Mr Y’s legs and requested the DN to assess. Later that day the DN dressed Mr Y’s legs and advised the home to observe for signs of sepsis.
28. The following day a paramedic assessed Mr Y’s legs. The notes say Mr Y should continue with his course of antibiotics but that he “won’t wear compression stockings”.
29. After a further checkup on 30 January 2024, medical professionals requested further antibiotics for Mr Y's legs due to the presence of discharge. On 9 February 2024 the DN noted, “legs looking better” and to be redressed twice a week. On 9 April 2024 the DN recorded “legs looking better but still a way to go”. However, three days later, the DN recommended “skin monitoring to be put in place”.
30. On 26 April 2024 Mrs W visited Mr Y. The visit happened to be at the same time as the DN’s visit to redress Mr Y’s legs. Mrs W says the DN asked to see the chart put in place by the home to monitor Mr Y’s bandages. The home confirmed there was no such chart.
31. The home has since explained that it decided not to introduce a chart because it felt a chart would not have prevented Mr Y from becoming distressed by the bandages and rolling them down. Instead, the home says it encouraged Mr Y to keep the bandages in place. Despite this, Mr Y would continue to roll the bandages down to relieve his discomfort.
32. Mrs W complained that Mr Y’s legs deteriorated because the bandages rolled down and cut into the sores. Following the visit in April, Mrs W decided to move Mr Y to a new home. She says within two weeks of being at the new home Mr Y’s legs healed and he no longer needed bandages.
33. The records show DNs assessed Mr Y’s legs eleven times between December 2023 and April 2024. However, there is no evidence to show how the home considered the DN’s recommendations came to the view that a monitoring chart was not in the best interests of Mr Y. The home has only provided this explanation retrospectively. Due to the lack of contemporaneous records, it is not possible to say how the home made its decision and what factors it considered. Although we cannot say on balance whether Mr Y’s legs healed at a slower rate because of this, the fault has caused uncertainty.

Complaint d)

34. Mrs W complained about poor standards of cleanliness in Mr Y’s room. As an example, she said there was blood stains on the wall from a fall Mr Y had in November. Mrs W says the same stain was still on the wall when Mr Y left in May.
35. She complained that Mr Y’s room was always a mess with food debris behind his chair and under his bed. Mrs W also said the bathroom was unclean.
36. In response to Mrs W’s complaint the home accepted that its housekeeping team should have done more to encourage Mr Y to come out of his bedroom to allow for deep cleaning. The home also acknowledged there were missed opportunities to clean Mr Y’s room at times when he was away from the home visiting family. This fault caused some distress to Mr Y.

Complaint e)

37. Mrs W complains the home did not do enough to reduce the risk of Mr Y falling. For example, she says the home refused to place a fall mat in Mr Y’s room which would alert staff to times when he had fallen.
38. The records show three documented occasions when Mr Y fell.
• 12 October 2023 – Mr Y was not wearing his shoes, and his walking frame was across the other side of the room.
• 6 November 2023 – Mr Y had one shoe on and one shoe off and his walking frame was across the other side of the room.
• 21 December 2023 – Mr Y had an unwitnessed fall and was found on the floor of his bedroom. He had a cut on his right elbow. Paramedics advised staff to move Mr Y from the floor and to call the DN to dress the wound. The DN dressed Mr Y’s elbow an hour later.
39. The home explained that Mr Y initially had a fall mat in place but staff established it was a trip hazard. The home also said that Mr Y would sometimes unplug the mat and carry it into the lounge asking staff to remove it for him.
40. We asked the home to provide supporting evidence to show how it weighed up the risks associated with the continued use of the mat. We also asked the home to provide evidence of any other preventative measures it considered or put in place to mitigate Mr Y’s risk of falling. The home did not provide any supporting evidence. In our view, the failure to keep Mr Y’s risks under review caused uncertainty because we cannot say, on balance, whether Mr Y’s falls were preventable.

Complaint f)

41. Mrs W complained the home did not encourage Mr Y’s participation with social activities. She also complained that staff did not have the correct resources to do planned activities such as gardening.
42. Because Mr Y liked to spend a lot of time in his bedroom, Mrs W purchased a large TV with a sports subscription. On visiting, Mrs W said the TV was often off despite Mr Y being sat in the room. She raised her concerns with staff.
43. Mr Y’s care plan says, “Staff to support [Mr Y] in watching football whenever on TV” and “staff to put [Mr Y’s] TV on for him when he is in his bedroom and select a sports channel of his choice…. [Mr Y] is unable to manage the remote control”.
44. In response to Mrs W’s complaint the home acknowledged that staff responsible for organising activities within the home did not always properly communicate with colleagues to ensure they had the correct support and resources for the activities. The home also accepted that it did not always put Mr Y’s TV on in his bedroom despite him paying for a sports subscription and the family expressing his preference to watch football. This fault caused some distress to Mr Y.

Remedial action

45. In response to Mrs W’s complaint, the home agreed to offer a financial remedy of £6,500. We asked the home to explain how it arrived at this amount. The home explained it “…took into account the amount of days at Nelson Lodge that the service did not meet the standards expected of the home in the delivery of care and services to [Mr Y] including daily housekeeping checks being missed, activities not organised and communicated correctly and where the home did not complete the dressing check as set out by the district nurses. This amount is equal to approximately one month’s fees of staying at Nelson Lodge….”
46. The home has also implemented the following service improvements.
• Employed a new ‘Activity Champion’ in the home to improve the activity schedule and resources. The home is also working to improve activity engagement and particularly for residents who prefer to stay in their rooms.
• Employed new members of the housekeeping team and have protocols in place to ensure that bedrooms are kept to a high standard and particularly for those residents who prefer to remain in their room.
• Introduced a new digital care planning system to enable staff to have more 1:1 interaction with residents. They will now spend less time completing paperwork. Staff can now add tasks to their planned care day to be tracked by management.
47. I have considered whether the personal remedy already offered by the home is proportionate and in line with what we would recommend. The Ombudsman’s Remedies Guidance suggests symbolic payments of up to £1000 for distress and uncertainty caused by fault. The payment offered by the home therefore exceeds our guidance for payments to remedy distress caused by uncertainty.
48. We may recommend a reimbursement of fees paid to a care home if we find the quality of care fell to an unacceptable standard or if part of a service was not provided as agreed. Depending on circumstances we may need to consider that some fees went towards residential care or other care that was satisfactorily received. Having considered the available records, I consider the home has already offered an appropriate remedy for the uncertainty and distress caused by the fault identified and I do not recommend a further refund for the fees paid.
49. However, the home has not provided a remedy for Mrs W who has experienced her own uncertainty because of the failures identified. For this the home has agreed to make a symbolic payment of £250 in addition to the apology Mrs W has already received.

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Action

50. Within four weeks of our final decision, the care provider will make a symbolic payment of £250 to Mrs W for the uncertainty caused by the fault identified in this statement.
51. Within twelve weeks of our final decision, the care provider will also implement the following service improvements in addition to those already completed:
• Remind relevant care staff (through a training session, briefing paper or updated policy document) of the need to keep risk assessments under review, as per Regulation 12. This should cover:
1. When medical professionals recommend measures to mitigate risks, such as skin monitoring charts, the home should ensure those recommendations are properly considered at the time and documented in the service user’s records. The home should also remind staff to clearly document any rationale for reaching a view which conflicts with the recommendations made; and
2. When staff decide to remove aids, such as fall sensor mats, the home should clearly document the rationale for the decision in the service user’s records and consider/assess any other preventative measures or aids it could put in place.
52. The Care Provider will provide us with evidence it has complied with the above actions.

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Decision

53. I have completed my investigation with a finding of fault causing injustice for the reasons explained in this statement. The payment already offered by the home to is an appropriate remedy and we do not recommend anything further for Mr Y. However, to fully remedy the injustice caused to Mrs W, the home has agreed to make a symbolic payment of £250.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman