Summary: The care provider did not act promptly to ensure that Mr X’s room was always clean and odour-free; in addition the care home manager suggested to Ms A (his daughter) that her complaint would affect his care. As a consequence Ms A moved her father from the home. The fault by the care provider caused injustice, and it will now make a suitable payment to recognise the distress its actions caused.

The complaint

1. Ms A (the complainant) says the care provider failed to keep the mattresses and carpets in her father’s room clean and odour-free but would not replace them with hard floors. She says the care home manager told her that her complaints would affect her father’s care.

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

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How I considered this complaint

5. I considered evidence provided by Ms A and the care provider as well as relevant law, policy and guidance.
6. Ms A and the care provider had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Relevant law and guidance

7. 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.
8. Regulation 15 says “Premises and equipment must be kept clean and cleaning must be done in line with current legislation and guidance. Premises and equipment should be visibly clean and free from odours that are offensive or unpleasant. Providers should take action without delay when any shortfalls are identified.”
9. Regulation 16 says, “Complainants must not be discriminated against or victimised. In particular, people's care and treatment must not be affected if they make a complaint, or if somebody complains on their behalf.”

What happened

10. Mr X moved into the care home as a resident in May 2023. Prior to admission the care home carried out an assessment. He was deemed to be fully continent at the time and had begun to suffer from dementia.
11. By the end of 2024 Mr X’s needs had increased. He needed help with managing his personal hygiene and used incontinence aids. He took a number of different medications which his care plan suggested contributed to an increased risk of falls. At that time, he also had crash mats at either side of his bed, as well as a chair and bed sensor. Ms A’s sister spoke to the care manager in August about the odour in her father’s room and asked about vinyl flooring being used instead of carpet.
12. In November 2024 Ms A contacted the care provider about the odour of urine in her father’s room which she believed was emanating from the carpet. She asked if the carpet could be replaced or an alternative flooring put down. The manager said she would explore options with the senior care team. Later that month the manager told Ms A that they would not replace the carpet with vinyl flooring “due to the risk factors involved and the unpredictable incontinence episodes”.

The complaint

13. In December Ms A complained to the care provider. She said despite repeated requests the carpet had not been cleaned or changed. She also said her father’s nails were dirty and his hair had been left to grow long; the brakes on his wheeled walker were broken; a carer had told her his crash mat needed changing but he hadn’t had a crash mat since August.
14. A manager responded. She apologised that Mr X’s appearance had been allowed to become unkempt and said he was often unwilling to allow carers to cut his nails. She apologised for a delay in informing her the rollator needed repair. She apologised for the miscommunication about the crash mats.
15. The manager also explained that the GP had said he would not refer Mr X back to the Dementia specialist team and asked the home to consider whether Mr X could still be classed as suitable for a residential placement.
16. The manager also addressed Ms A’s concerns about her father’s incontinence. She asked if Ms A could discuss this with the senior carer rather than individual carers so she could hear the overall information rather than random episodes.

Finally the manager also addressed the concerns about the odour in Mr X’s room. and the possibility of replacing the flooring (Ms A’s preference). She said “I understand that it was felt that the urine smell was not coming from the carpet, but the mattress. It was felt that laminate flooring would be more of a risk due to your dad being a risk of falls.”

17. Ms A complained again, as she was dissatisfied with the response. She said she was concerned about the mixed messages she was receiving from the home management. She said she had viewed other care homes where wooden or laminate flooring was in place and could not understand why it would be a problem if it prevented the continued odour. She said at a meeting with managers her family’s concerns had been dismissed and a manager had said to her the “the circle of trust is broken and this will affect care”. She said when her sister asked about the home’s lack of provision for residents from a non-Caucasian background, the management staff had laughed and left the room.
18. The operations support manager responded. Again he apologized for errors in fact and poor communication. He apologized if comments made by staff in respect of hard flooring had been seen as flippant: He said the main concern was about Mr X’s safety if he fell. He said the carpet had been cleaned according to schedule and sometimes more regularly. He added that the carpet had now been replaced.
19. The operations manager apologized if the comments of the managers had been inappropriate but he said there was no evidence to suggest Mr X had been treated differently as a result of the complaint. He said that the managers who had left the room without concluding the meeting had genuinely believed that their actions were for the best as the meeting had become heated. He said their actions were “regrettable” and added “Moving forward, we will provide guidance on maintaining professionalism, even during challenging discussions, to ensure such situations are handled respectfully”.
20. Ms A moved Ms X from the home. She complained to the Ombudsman. She said that managers had given her false information, she had concerns about the poor environment her father was living in and was worried about repercussions for her father as the manager had told her his care would be affected by her complaints.
21. The care provider says that where mattresses need to be replaced as unsuitable or unsafe then they will be. She says waterproof mattress protectors are used throughout the home as a matter of course.
22. The care provider says the use of vinyl or other hard flooring is dependent on the needs of the individual resident. She says “In this case, the primary concern cited was the increased falls risk associated with hard flooring. The decision prioritised safety, as hard flooring could increase the risk of falls, potentially leading to serious injuries, such as fractures.”
23. In respect of the comments made that Ms A’s complaints would affect her father’s care, the care provider says “we have recognised that the terminology used by the Home Manager was inappropriate and misused. We sincerely apologise for this incident and have taken action to ensure that Home Managers are reminded of the importance of ensuring they maintain the highest level of professionalism, avoiding comments or judgments that may appear inappropriate or untrue”.

Analysis

24. There were multiple instances of poor or inaccurate communication from the care provider. It has acknowledged and apologized for those but that inevitably led to distrust by Ms A and her family.
25. It appears there was a continuing failure to ensure Mr X’s room was odour-free in line with the regulations. There is no convincing evidence to suggest the care provider took action without delay as it should have done and this was therefore a potential breach of the regulations.
26. The care provider has explained that its main concerns were about the risk to Mr X of falling on a hard floor. Had it taken the time to explain that much sooner to Ms A the consequences would have been less.
27. Of particular concern was the intimation by the care home manager that Ms A’s complaint would lead to recriminatory action of some sort against her father. The care provider has apologized for this and reassured Ms A there was no evidence this happened, but the injustice caused to Ms A as a result of this unprofessional threat was significant. Not surprisingly she moved her father to another home. It was another potential breach of the regulations.

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Action

28. Within one month of my final decision the care provider will acknowledge the injustice suffered by Ms A as a result of the home management response to her complaints and to Mr X of having to be moved as a result of the fear of the effect on his care. It will offer £1000 (£500 each) to Ms A and her sister and a further £1000 to Mr X.
29. Within one month of my final decision the care provider will provide details to us of the guidance and training it has issued to managers to avoid a recurrence of their attitudes towards people who make legitimate complaints.
30. The Care Provider should provide us with evidence it has complied with the above actions.

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Investigator's decision on behalf of the Ombudsman