Summary: Mrs X complains the Council failed to ensure her mother, Mrs Y, received the care she had been assessed as needing at Blandford Grange Care Home, and failed to carry out proper safeguarding enquiries into her concerns. The Care Home did not always meet Mrs Y’s needs, which could have put her at risk of harm, although there is no evidence of significant harm to Mrs Y. Nevertheless, the Council needs to apologise to Mrs X for the distress caused to her and her mother.

The complaint

1. The complainant, Mrs X, complains the Council failed to ensure her mother, Mrs Y, received the care she had been assessed as needing at Blandford Grange Care Home and failed to carry out proper safeguarding enquiries into her concerns.

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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. 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)
4. 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)

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How I considered this complaint

5. I have considered evidence provided by Mrs X and the Council, as well as relevant law, policy and guidance.
6. Mrs X, the Council and the Care Hone had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

What happened

7. Mrs X’s mother, Mrs Y, has dementia, diabetes and other age-related conditions. Mrs Y moved to the Care Home in February 2023. The Care Home produced care plans for Mrs Y, which it updated regularly. The care plans set out Mrs Y’s needs and preferences. They also identified the need to contact Mrs X if her mother declined care. By way of summary, Mrs Y needed:
• a full hoist and a specific sling for transfers
• repositioning in bed every four hours with a slide sheet, to reduce the risk of tissue breakdown. Mrs X gave the Care Home permission to reposition Mrs Y without waking her, as she often declined repositioning if woken
• hourly safety checks done and recorded as appropriate
• her feet elevating when sat in her reclining chair
• a V shaped cushion placed at the level of her lower back and brought through her legs when in bed
• a motion sensor turned on when in bed
• her mobile phone charged and left within reach
• a call-button left within reach
• help having a bath once a week
• easy to chew food (i.e. which can be cut or broken easily with the side of a fork or spoon)
8. Mrs X discussed her concerns about her mother’s care with the Council in November 2023. The Council discussed the concerns with the care home.
• The Care Home confirmed they wanted to work with everyone to ensure Mrs Y could remain there.
• The Care Home agreed to address the concerns raised by Mrs X and to address issues with the staff concerned.
• The Care Home confirmed they looked for signs of Mrs Y being in pain and did not necessarily wait for her to say she was in pain before giving her pain relief. The Care Home agreed to tell Mrs X about any health updates and GP visits.
• They agreed the need to improve the channels of communication, as the Care Home was getting busier. So Mrs X should first speak to the nurse in charge, who would communicate with the Care Home’s manager and the care provider (Healthcare Homes (LSC) Limited, which runs the Care Home). To contact the Council if issues continued.
9. Mrs X told the Council neither she nor her mother wanted her to move to another care home. The Council agreed to pass her concerns on to its quality improvement team. It noted her concerns related to cleanliness of the environment, the approach of staff, staff not being aware of Mrs Y’s deprivation of liberty safeguard, and general communication failures.
10. In December the Care Home told the Council it had actions in place to address Mrs X’s concerns. They agreed to have a full review in the new year. Mrs X was not aware of this.
11. In January 2024, Mrs X told the Council her mother may need mental capacity assessments for other decisions, such as being woken at night to reposition her. Before reviewing Mrs Y’s needs, Mrs X told the Council her concerns included: management style at the Care Home; the staff’s poor understanding of dementia; meal choices; warmth; relative’s meetings; the lack of one-to-one activities; nail care; cleanliness of the bathroom, floor, chair and toothbrush; bathing and use of a sling; medication found on the floor; no insulin when Mrs Y went to hospital; and her mother’s black eye.
12. Mrs X complained to the care provider about her mother’s care on 8 February.
13. Mrs X told the Council a care worker, who had not completed moving and handling training, had helped another care worker to support her mother. The care provider arranged for the care worker to receive moving and handling training before assisting with this again.
14. The Council reviewed Mrs Y’s needs with the Care Home and her family on 19 January. Mrs X disputes many of the contents of the record of the meeting. She also says the Care Home did not consistently deliver the promised improvements.
• The Care Home confirmed the correct sling was now in place for Mrs Y and that it had taken some time to get this.
• The Care Home agreed to look at what one-to-one activities were being offered. It also agreed to do Mrs Y’s nails regularly.
• Mrs X showed photos of a tablet on the floor, bedrails partly down, an unclean toothbrush and Mrs Y’s black eye. This prompted much discussion, but no conclusions. No one could explain the cause of Mrs Y’s black eye. The Care home apologised for not reporting back to Mrs X after she found medication on her mother’s floor.
• Mrs X confirmed the use of gloves had improved but not repositioning her mother. The Care Home said it had ordered nail cleaning kits and told staff it was now part of Mrs Y’s care plan.
• Mrs X said staff were not cleaning her mother’s toothbrush and there were food stains on the floor. The Care Home said it told staff to clean up immediately and once a month staff cleaned the room.
15. On 23 February the Care Home held a meeting with Mrs X and her mother, to discuss Mrs Y’s care plan. They agreed:
• The Care Home would update Mrs Y’s care plan to reflect:
1. the need to change gloves between washing and to apply cream to her front area, and the need to wash and apply cream to her buttocks;
2. the agreed positioning of Mrs Y’s V cushion. Mrs Y agreed to continue using it, although it made her hot and sweaty because of the temperature in her room;
3. the need to wear a new jacket to keep Mrs Y warm after a bath;
4. the need to use an inflatable bowl when washing Mrs Y’s hair when she wasn’t having a bath;
5. the need to clean Mrs Y’s nails with orange sticks.
• The Care Home would train staff over the uses of Mrs Y’s prescribed creams.
• Mrs X would resend information about a window film, to help reduce the temperature in Mrs Y’s room.
• The continued use of finger pricks to check Mrs Y’s blood sugar levels, as requested by her GP.
16. The Care Home met Mrs X on 12 March to go over her concerns and agreed these actions:
• Taking minutes at future relatives’ meetings.
• Source an appropriate tint for the window in Mrs Y’s room.
• Lines of communication were confirmed.
• Staff to ensure Mrs Y’s TV was on and switched to a suitable channel.
• Make no further referral to occupational therapy.
• A member of staff had to leave part way through their shift on 5 March, leaving the unit short of staff in the afternoon. The Care Home would review staffing by 15 March to ensure only one person went on a break at a time.
• Staff to check Mrs Y’s feet correctly every day (redness noted behind toes and heel). Assist Mrs Y to sit upright and high up the bed, to prevent her feet pressing against the bed-board. Pressure boots to be worn, as required.
• During hourly checks, staff to check for odour indicating bowel movement.
• Help Mrs Y with a bath and hair wash every Tuesday.
• Staff to be shown how to use Mrs Y’s electric toothbrush and stand correctly.
• Staff to ensure personal care after incontinence was thorough and gentle, to reduce pain from haemorrhoids.
• Keep bedrails up when not delivering care, even when staff were in the room with her.
• Ensure bed controls were within Mrs Y’s reach, so she could readjust the bed’s position.
• Ensure the call pendant was within Mrs Y’s reach.
• Ensure Mrs Y’s mobile phone was charged (overnight) and left within her reach.
• Offer breakfast cereals around 7am each day, gently waking Mrs Y up if necessary. Offer toast and eggs an hour later, if that was what she preferred.
• Display a reminder memo in Mrs Y’s room to prompt staff how to deliver care.
• Staff to give Mrs Y her medication at the end of the medication round, so they had time to make sure she took all her tablets without feeling rushed (tablets had been found on the floor).
• Clean the carpet and reclining chair in Mrs Y’s room on the third Tuesday of each month.
• Remind staff of the mobile phone policy and monitor compliance daily.
• A trainer to observe new staff to ensure compliance with policies.
• Send Mrs X a copy of Mrs Y’s electronic records before the next meeting on 12 April.
• Managers to monitor progress in delivering the above actions via the daily management walkaround.
17. On 14 March Mrs X said they had also agreed:
• Staff to cut up Mrs Y’s food before giving it to her and give her a spoon to eat it with.
• Provide Mrs Y with a “cover-all” when eating, to prevent food getting on her clothes.
• Keep Mrs Y’s fingernails very short and clean under them every day, as she mainly ate with her fingers.
• Add Mrs Y to the list to have her hair cut (short) every six weeks.
18. On 20 March the Care Home e-mailed Mrs X, responding to concerns she had raised a few days earlier. It said:
• Staff had waited for Mrs X to visit before telling her Mrs Y’s toothbrush was not working. Manual toothbrushes were available if the electric toothbrush could not be fixed or replaced.
• Mrs Y’s feet had been raised in line with her care plan. Staff had checked the condition of her feet meticulously. They were neither red nor marked. When recumbent on her chair, her feet took on a reddish hue, but this dissipated when lying down.
• It was sorry fish arrived served incorrectly. They would monitor and remind staff of the need to cut Mrs Y’s food up before serving it.
• Staff confirmed the cradle to protect Mrs Y’s feet had been in place and had not fallen on her legs while they were with her. They had noted the need to encourage Mrs Y to attend activities which may be of interest to her.
• One hoist was out of order and should be repaired within the week. Other hoists could be used in Mrs Y’s unit, if necessary.
• The daily notes confirmed creams had been applied to Mrs Y’s skin, in line with her care plan. Any concerns would be reported
19. A follow up meeting was arranged for 12 April. There is no record of the meeting, which Mrs X says lasted for several hours, including a break for lunch.
20. On 18 April the Council received safeguarding concerns from Mrs X, which she had sent to the Care Quality Commission (CQC). She said:
• The quality of care in the Care Home had gone down after it started employing staff from overseas in August 2023;
• The Care Home’s manager had verbally abused her in a review meeting for her mother in January 2024.
• Two out of three hoists were out of action in a home with over 60 residents;
• She believed the Care Home was understaffed, with four care workers and a nurse on one floor and three care workers and a nurse on the other floor;
• At the meeting on 12 April, the Care Home told Mrs X she had one month to improve her trust, otherwise it would reconsider her mother’s placement.
• The plans agreed for meeting Mrs Y’s needs had been disseminated to staff and the care delivery reminder had been put up behind Mrs Y’s bed.
21. On 25 April the Council told Mrs X it would send her concerns to the Care Home for a response. Mrs Y agreed to this, but said she was concerned about repercussions. The Council told her “staff should always be professional regardless”.
22. A further meeting had been arranged for 12 May, but this did not go ahead.
23. The care provider contacted the Council on 16 May giving it notice to move Mrs Y to another care home.
24. Mrs X e-mailed the care provider on 17 May, raising a number of concerns.
25. When the care provider replied to Mrs X’s complaint on 6 June, it said:
• It gave notice to the Council, not Mrs X, because the Council arranged her mother’s placement in the Care Home.
• It did not give Mrs Y notice to leave because Mrs X had made a complaint, but because of a breach of trust and confidence between the Care Home and Mrs X. On 17 May the Council confirmed it would find an alternative placement for Mrs Y.
• On 22 April it had set a date for a meeting with Mrs X on 12 May. On 10 May the Council proposed cancelling the meeting, as Mrs X remained dissatisfied following the meetings on 12 March and 12 April. Although the Care Home felt confident about meeting Mrs Y’s needs, it found it difficult to meet all Mrs X’s expectations.
• It disputed the claim that there had been no written response to Mrs X’s concerns. It had sent e-mails following the meetings on 12 March and 12 April, setting out the actions to be taken. Mrs X did not respond to the e-mail sent on 22 April.
26. The Care Home’s records show Mrs X was very involved in her mother’s care and had regular contact with the Care Home. They show Mrs Y was frequently washed on her bed, rather than taken for a bath/shower, without any explanation (i.e. whether this was at her request).
27. Mrs Y moved to another care home in December. Mrs X says her mother has settled at the new home, which is clean and well maintained. She says her mother spend time with other residents, is eating well and goes on weekly trips in a minibus. She says this is in stark contrast to the life she experienced at Blandford Grange Care Home.

Is there evidence of fault by the Council which caused injustice?

28. The evidence shows there were lapses in the care provided by the Care Home, which included:
• A delay in providing a sling which resulted in Mrs Y being cared for in bed longer that should have been the case and unable to access a bath/shower
• Medication on the floor, which could have put Mrs Y at risk of harm
• Food was not always served properly
• Frequent bed baths, which was not in line with Mrs Y’s care plan, without any explanation
• A member of staff supporting Mrs Y with hoisting who had not been trained to do this
• A lack of cleanliness in Mrs Y’s room (e.g. toothbrushing equipment, spillages left on the carpet)
29. There is no evidence these issues caused significant harm to Mrs Y. Nevertheless, they caused avoidable distress to Mrs X and her mother.
30. Giving notice to someone in a care home should always be a last resort, as moving an elderly person can put them at risk of harm. Sometimes it cannot be avoided, for instance if a care home can no longer meet someone’s needs. But that was not the case with Mrs Y. People should not be evicted because people have made complaints. The care provider denied this and said it was because of a breach of trust and confidence. But the fact remains that Mrs X’s lack of trust and confidence was reflected in her complaints. If a care provider is minded to give notice because of a breakdown in the relationship with a relative, we would expect it give a warning of its intention and provide an opportunity to agree a way forward with a view to avoiding this. The care provider did this at the meeting on 12 April 2024. However, Mrs X’s lack of confidence in the Care Home resulted in her raising safeguarding concerns with CQC. It appears that is what prompted the Council and the care provider to decide the Care Home would not be able to meet Mrs X’s expectations. That does not reflect fault on the part of either party. In principle, it should have been possible to resolve Mrs X’s concerns, but it became clear that was not going to happen.

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Action

31. When a council commissions or arranges for another organisation to provide services we treat actions taken by or on behalf of that organisation as actions taken on behalf of the council and in the exercise of the council’s functions. Where we find fault with the actions of the service provider, we can make recommendations to the council alone. Here we have found fault with the service of the care provider, and make the following recommendations to the Council.
32. I recommend the Council within four weeks writes to Mrs X apologising for the distress she and her mother were caused by the failure to meet all Mrs Y’s care needs.
33. The Council has agreed to do this. It should provide us with evidence it has complied with the above actions.
34. Under the terms of our Memorandum of Understanding with CQC and information sharing protocol, I will send it a copy of my final decision statement.

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Decision

35. I find fault causing injustice. The Council has agreed to take action to remedy the injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman