Summary: Mrs X complained on behalf of her sister that she had not received appropriate care in the home managed by Bureaucom Limited. The Care Provider had not done enough to make sure that Mrs B’s oral health was maintained and did not record a review of risk and support when she fractured her toes meaning that she was more likely to fall. These shortcomings caused Mrs X and Mrs B distress and uncertainty. The Care Provider should apologise to Mrs X and make a payment to her and her sister in recognition of the distress it caused them.

The complaint

1. Mrs B is represented by her sister, Mrs X. Mrs X complains that the Bureaucom Limited, the Care Provider, failed to give Mrs B proper care. In particular, it failed to make sure that she had proper oral care; it did not seek the right medical help when Mrs B had several falls; and it did not do enough to prevent falls.
2. Mrs X says that as a result of the Care Provider’s failings, her extremely vulnerable sister suffered significant pain and was on the verge of sepsis from an infection in her mouth. The Care Provider also failed to support Mrs X when she had to find her an emergency dentist and its shortcomings caused Mrs X herself distress.

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The Ombudsman’s role and powers

3. 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)
4. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
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)
6. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)

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How I considered this complaint

7. I considered evidence provided by Mrs X, the Care Provider and the local authority in its safeguarding role, as well as relevant law, policy and guidance.
8. Both Mrs X and Bureaucom Limited had an opportunity to comment on my draft decision. I considered any comments before making a final decision.
9. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

The law and guidance

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
11. The fundamental standards include that the provider must give care that is person centred and safe, and must safeguard the person from abuse or improper treatment.
12. 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.
13. A council must make safeguarding enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

What happened

14. Mrs B is disabled and has complex care needs, including that she is mute with limited communication and that she lacks capacity to make decisions about her care. She lived in a residential care home managed by Bureaucom Limited (the Care Provider) which she funded herself. Her sister, Mrs X advocates for her. Mrs X says she has often had concerns about Mrs B’s care while she was living there, but from 2022 this deteriorated.
15. In April 2024, the Care Provider told Mrs X that her sister was limping badly. It had reviewed the care records from the day before but these said Mrs B had been mobilising as usual. Paramedics attended but advised that Mrs B did not need to be admitted to hospital. The Care Provider consulted the GP who referred Mrs B for an x-ray.
16. The hospital found Mrs B had two fractured toes and it fitted a boot with the instructions that Mrs B rest the foot. However, four days later Mrs X found the Care Provider had taken the boot off. The Care Provider’s notes show that the physiotherapist advised that Mrs B could take the boot off as it did not aid healing and was for comfort.
17. A week later Mrs B fell and wounded her head deeply. She was taken to hospital. The Care Provider said the fall was unwitnessed.
18. Two days later, Mrs B had another fall and cut her head deeply and hurt her hand. Again, this was unwitnessed. She was attended by paramedics who applied steri-stiches. Mrs X told the staff that Mrs B clearly needed help mobilising as she was recovery from fractured toes. Mrs X raised a safeguarding concern with the local authority.
19. Following this, the district nurse visited Mrs B twice to check on her wounds and apply dressings where needed. The care notes say the district nurse noted Mrs B’s hand was very swollen and that staff should monitor this.
20. Mrs X says that around five days later, she found her sister’s hand was very badly bruised and severely swollen and she asked the Care Provider to arrange an x-ray. Mrs X took Mrs B to the hospital that day. It found a fracture across her wrist and the hospital said Mrs B would have been in agony.
21. The same day, Mrs X noticed that her sister’s other hand was bruised and she could not open it. Mrs X says she asked the Care Provider about this but the manager said the staff had not noticed this. Mrs X took her sister back to the hospital. It discharged Mrs B with a wrist support referral to physiotherapy and Mrs X says the hospital said her sister should use the wrist support for at least a week. However, when she visited the next day, the Care Provider had removed it.
22. The Care Provider had notified the CQC of Mrs B’s falls and Mrs X had also notified the local council. The council considered these safeguarding issues but decided that the Care Provider had sought medical advice and treatment appropriately and it did not need to make any further safeguarding enquiries.
23. The Care Provider has sent me its records. These show that as well as seeking help from the GP and emergency services, it had supported Mrs B in the follow up fracture clinic, physiotherapy and district nurse appointments and followed advice. The Care Provider put a pressure mat in Mrs B’s room that would alert staff if she fell or moved from her bed. It also arranged hip protecting padding to minimise the risk of injury if she fell.
24. The Care Provider says that following the fractured foot, it supported Mrs B to mobilise with two carers. However, Mrs B did not understand that her balance and mobility was affected and so she would get up to walk without help and this put her at risk of falls.
25. The Care Provider reviewed Mrs B’s care in June and updated its risk assessment. It identified her risk of fall but by this time, Mrs B only needed one carer to support her when mobilising.
26. The Care Provider had made referrals to a dentist but had not been able to register Mrs B with an NHS dentist and so entered her onto the waiting list for this. The Care Provider’s notes say that Mrs X arranged a dentist for Mrs B and had been taking her to appointments.
27. The Care Provider’s notes say that it was concerned there was something wrong with Mrs B’s mouth or teeth in May, and it sought an urgent appointment with a dentist. The Provider’s care review in mid-June noted that Mrs B still needed an urgent dental appointment.
28. In late-June, Mrs X was concerned that Mrs B had an extremely sore mouth and could not eat properly. She was clearly unwell and could not keep food or fluids in her mouth. The Care Provider contacted a GP who prescribed antibiotics. It also referred Mrs B to a speech and language therapist to see if she had problems with swallowing. However, the therapist decided that a swallowing assessment was not needed at that time.
29. The Home Treatment Team (an NHS service of medical professionals providing care to residents) examined Mrs B the next day and thought she may have dental abscesses. Mrs X was present and said this examination was very difficult and distressing for her sister. The Team advised the Care Provider that Mrs B would need to see a dentist that day. The Provider called the NHS helpline and the dental helpline number but could not get Mrs B an appointment. Mrs X says there was pus coming from Mrs B’s mouth and she needed medical help urgently. Mrs X called several dentists until she got her sister an appointment.
30. Mrs X took Mrs B to the dentist who found that she had a severe mouth infection, with pus and blood, and possibly sepsis.
31. Mrs X says the doctor confirmed that her sister would be in severe pain from her injuries and the infected mouth. Mrs X, the dentist and the hospital raised a safeguarding concern with the local authority that her oral health had got so bad.
32. Mrs X describes Mrs B’s care as generally poor, where her nails were not cut regularly or kept clean, she was often sat in wet clothes, and many items went missing and were never returned including new clothes, jewellery and equipment.
33. Mrs B moved from the hospital to a different care home. Mrs X complained to the Care Provider.
34. The Care Provider did not uphold any of Mrs X’s complaints. It said:
• It had completed all the relevant risk assessment and care plans for Mrs B, and these were reviewed and updated monthly or more often as needed.
• Her care records show that she has received appropriate care.
• Medical interventions were recorded in detail. These included that it had consulted the clinical pharmacist, and made a referral to the community physiotherapist, and instigated a medication review to check calcium levels following her foot fracture.
• It had consulted the practice nurse by telephone regarding her hand not opening and followed the advice of the surgery with antibiotics.
• The physiotherapist advised that they remove the boot to help her mobility, and they put a pressure mat in place.
• It put more support in place following the risk of falls and injury.
• The staff provided oral care in line with her care plan. She was eating as normal with a soft consistency diet up until 26 June. It referred her to the doctor who visited on 27 June. It had made timely referrals but she was on a waiting list for an NHS dentist.
35. In October, the CQC completed an inspection and found poor care. It placed the home in special measures.

Did the Care Provider’s actions cause Mrs B or Mrs X injustice?

36. I asked the Care Provider for the records of Mrs B’s oral care. It has not sent me these, so I cannot see whether staff were able to brush her teeth, or whether she was refusing this. The lack of records is fault. The Care Provider has sent me details of Mrs B’s food and fluid intake which shows that Mrs B was eating normally right up until it became aware that she was not holding food in her mouth.
37. The Care Provider’s oral care policy and procedure sets out approaches where the person refuses oral health care, such as brushing in a different part of the mouth each day or offering an alternative to brushing. It says in these cases, it will involve the family and record on the oral health plan how it will manage the person’s refusal.
38. Mrs X says that Mrs B’s toothbrush was little used. If the Care Provider was unable to brush Mrs B’s teeth, it should have spoken to Mrs X about this, looked at other ways to maintain Mrs B’s oral health, and recorded this on her care records, in accordance with the policy.
39. I can see that the Care Provider sought advice from the GP and tried to arrange a dentist appointment, but by that stage the situation was extremely urgent and Mrs B had to be seen that day. The Care Provider’s records show that it had identified that Mrs B needed an urgent appointment in May. The Care Provider did not do enough to chase up the referral it made to the dentist when an appointment was not forthcoming. The lack of safe and person-centred care is a potential breach of the fundamental standards.
40. I cannot say that had it done so, a dentist would have seen Mrs B sooner, or she would have avoided such a serious infection. However, the urgency of the situation with which Mrs X was presented in late June, caused her and her sister distress.
41. The Care Provider had considered Mrs B’s risk of falls in its risk assessment and care plans. It cannot entirely prevent falls. It sought medical help from the GP and the paramedics when Mrs B was limping and when she fell and injured her head. It engaged properly with the follow up appointments and followed the advice of the hospital and the physiotherapists. It also took action to minimise the harm from any further falls by installing the pressure mat and arranging for Mrs B to have hip protecting padding. Mrs X says the lead to the pressure mat was a trip hazard and she believes it caused one of her sister’s falls. Mrs X says the Care Provider should have put in bed rails instead.
42. The Care Provider said that when the hospital found that Mrs B had fractured her foot, it realised that her mobility would be affected and that she would not understand that she needed to be more careful and rest her foot. The Care Provider said that it made sure that Mrs B had two carers to support her with walking at this time. I would have expected the Care Provider to have reviewed its risk assessment and support plan in light of this (even if it was by way of a note on the care records). The Care Provider did not review the risk assessment until two months later.
43. I cannot say that the Care Provider did not arrange for two carers to support Mrs B and I recognise that even with this level of support, Mrs B was likely to mobilise independently and put herself at risk due to the impact of her health conditions. However, the lack of recorded review of the risk and support needed leaves Mrs X uncertain that the Provider could have better protected her sister.

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Action

44. The Care Provider should within one month of the date of this decision:
• Apologise to Mrs X for the fault I have found and the impact on her and her sister. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
• Pay to Mrs X and Mrs B symbolic payments of £300 each to recognise the distress its shortcomings caused them both.
• Remind staff that oral care should be recorded and the policy followed, and that it has to follow up requests for medical appointments if these are not forthcoming.
45. The Care Provider should provide us with evidence it has complied with the above actions.

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Decision

46. I have completed my investigation and uphold Mrs B’s complaint. It is likely that the Care Provider’s actions caused her injustice. I have made recommendations to remedy injustice the organisation has not yet agreed to carry out. The Care Provider should take the action recommended to remedy injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman