Summary: Mrs X complained for her husband Mr X about his care in a council-funded care home. We found fault as care did not reflect Mr X’s preferences, he was not supported to walk, he had only infrequent showers and did not get enough opportunities to take part in activities he was interested in. The Council will apologise, make symbolic payments to reflect avoidable distress and complete a review by the quality assurance team.

The complaint

1. Mrs X complained on behalf of her husband Mr X about his care in St Katherine’s House, Wantage, (the Care Home) which the Council arranged and funded.
2. She complained about:
1. A failure to promote Mr X’s independence (not supporting him to walk, using a hoist, not supporting him to sit out of bed including not having his meals out of bed and at the table)
2. A lack of activities
3. Long periods left in his room
4. The call bell being left out of Mr X’s reach
5. Providing inappropriate food
6. A failure to act on the advice of a physiotherapist
7. Infrequent showers (once a week)
8. Putting Mr X to bed at 7pm
9. Inadequate staffing numbers
10. Prescribing a sedative medication.
3. Mrs X said this caused avoidable distress.

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The Ombudsman’s role and powers

4. 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)
5. 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).
6. The Council arranged and funded Mr X’s placement at the Care Home under powers and duties in the Care Act 2014. We can investigate the Care Home’s provision of care to Mr X.
7. 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)
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I have investigated

9. I have not investigated complaint (i) because we do not have the expertise to determine staffing numbers. It depends on the residents’ needs overall and we cannot decide this without access to the care records of everyone who was in Mr X’s unit. We can only look at the care Mr X received.
10. I have not investigated complaint (j) because this was the GP’s decision. Mrs X needs to use the NHS complaint procedure for this complaint.

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How I considered this complaint

11. I considered evidence provided by Mrs X (including her complaint and photos) and the Council as well as relevant law, policy and guidance.
12. Mrs X, the Care Provider and the Council 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

Relevant law and guidance

13. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. When investigating complaints about council-funded care placements, we consider the 2014 Regulations when determining complaints about poor standards of care.
14. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
15. Regulation 12(i) of the 2014 Regulations says a care provider must provide care and treatment in a safe way including by
• working with health professionals to ensure the health and welfare of residents.
• assessing risks to the safety of people using the service and doing all that is reasonably practicable to mitigate risks.
16. Regulation 14 of the 2014 Regulations says the nutrition and hydration needs of residents must be met. They must receive suitable nutritious food and fluid to sustain life and good health, with support to eat and drink if needed.

What happened

17. Mr X has a degenerative condition which affect his thinking, movement and behaviour. He lived in the Care Home, which the Council funded, for five months in 2024. He moved to a different care home in September.

The Care Home’s care plans

18. The Care Home kept care plans which described Mr X’s needs and preferences and set out the care he needed. They said:
• He loved music, playing the piano and liked taking part in musical activities. He also loved football. His family were very important to him and should be made to feel at home when visiting him
• The physiotherapist (PT) visited in June, observed Mr X walking and advised two staff support him to walk to the dining room with a third walking close behind him with the wheelchair. The PT visited again September and gave similar advice.
• He needed three staff to support him with transfers, using a standing aid.
• Mr X could not use the call bell, but he would short out for help. A sensor mat needed to be in place. He should sit out of bed for meals.
• He had a normal diet cut into bite sized pieces. He could state his food and drink preferences. His favourite foods were fish and chips, steak, bread and butter pudding and vanilla ice cream
• He liked a daily shower and needed two staff to support him with personal care.
• In the evening, Mr X should not go to bed ‘too early’ as this made him agitated. He liked watching TV in the lounge.

Daily records

19. Care staff kept a daily record of interventions. They showed Mr X had a full body wash every day and a shower once or twice a week. Staff rarely recorded they offered a shower and he had refused.
20. There are no records of staff supporting Mr X to walk. Nor are there any records of support in the evening/bedtime. It is not possible to tell from the records what time staff helped Mr X into bed.
21. Staff also kept records of Mr X’s food and fluid intake. These recorded he had a good appetite, mostly ate all the food offered and had fish and chips most weeks. He weighed 82.2 Kg in March 2024 and 84 Kg in July.
22. The activities co-ordinator kept a record of activities offered and provided. Some entries said Mr X was watching TV. He was invited to attend some scheduled activities and did not always agree to. He took part in a lunch club, played with the therapy dog, attended a party for another resident’s birthday, music reminiscence, singing and zumba. The records indicate there was an organised activity about twice a week, which Mr X was invited to attend.

Communication by professionals

23. A note of a call between a physiotherapist and Mr X’s social worker at the end of April said:
• Mr X was not safe to walk along the corridor with two carers.
• He needed assistance of two carers to walk in the room and constant supervision if in a chair due to his impulse to get up unaided.
• Staff should use the hoist if he was weak and wobbly
• It might be worth placing a seat sensor if he was sitting out. It was unclear how soon carers could respond as they could be caring for others
• The physiotherapist’s view was Mrs X had unrealistic expectations of care staff and appeared not to fully understand Mr X’s condition is degenerative.
24. A note of a call between a specialist nurse and the social worker, also in April said:
• The Nurse said the Care Home was trying hard to accommodate Mr X’s family’s requests about how best to meet Mr X’s needs. He didn’t appear to have lost weight and looked the same weight as before the hospital admission
• Mr X’s needs were escalating and he suffered multiple falls at home. The Care Home was an organisation and so had to ensure he was safe and so there would be times he would be in bed for his safety
• The nurse had asked Mrs X to step back and let the Care Home get on with their job
• Sensory mats and high-low beds would need to be used by the Care Home to minimise falls risks. Mrs X believed using assistive technology like this was undignified.
25. The social worker also had a discussion with the manager of the Care Home in April:
• The hoist had been used because Mr X was too unsteady to use the sit to stand aid
• Mrs X was unhappy that Mr X had not been supported to walk
• The bed had been lowered to minimise the risk of harm as Mr X tried to get out of bed on his own. Mrs X said this was undignified
• Mrs X was upset about the wait for Mr X to see a PT so the Care Home had asked for an urgent visit
• Mrs X did not accept the reason for Mr X’s decline was his illness
• Mrs X wanted Mr X to be in the residential unit. But he needed nursing care where the staff had appropriate training and so needed to be in the nursing unit
26. The social worker and Mrs X spoke in April. Mrs X was unhappy with various aspects of Mr X’s care including transfers, walking, meals and mealtimes and she suspected weight loss.
27. Mrs X complained to the Care Provider. Its response said:
• Mr X was not ‘bed bound’ and the records showed he spent time in the main lounge or in his room watching TV after 7 pm.
• He needed two carers and a sit-to-stand aid according to the Care Home’s assessment
• He had his breakfast in his room and lunch and tea in the lounge
• Mr X was given soft easy to chew meals as recommended in the hospital discharge summary. His weight increased from admission to August and then fell (back to admission weight) due to a decline in health
• Staff notice a decline in Mr X’s mobility and arranged for him to see the PT. They recommended three staff to support him to walk
• Staff offered a daily shower, in line with Mr X’s care plan. Depending on his mood, he sometimes said no. If he had declined, staff would ask again later
28. Photos from Mrs X show Mr X sitting in a chair in the lounge. His call bell is out of reach and the movement sensor pad is not near the chair because the leads to the call bell and sensor pad do not reach where the chair is positioned in front of the TV. There is no call bell in one photo.
29. The Care Home has disclosed some call bell records which indicate Mr X could and did use the call bell often. Response times are under 3 minutes.

Comments from the Council

30. The Council told me it had reviewed Mrs X’s complaint and its Quality Assurance Team had carried out a monitoring visit to check on the standards of care in the Care Home. It also said Mr X’s care was not in line with its expectations.

Findings

A failure to promote Mr X’s independence (not supporting him to walk, using a hoist, not supporting him to sit out of bed including not having his meals out of bed and at the table)

31. Using a hoist was not fault; it was a safe way for staff to transfer Mr X if he was unsteady. His care was in line with Regulation 12 and there is no fault.
32. The records indicate Mr X was often supported to access the communal areas at mealtimes and in the evening in line with his care plan and Regulation 9. There is no fault.

A lack of activities

33. The records indicate the Care Home had only a limited number of scheduled activities and some of these were not in line with Mr X’s preferences. On balance, the Care Home could and should have done more to promote Mr X’s individual interests. His care was not individualised in line with Regulation 9 which was fault, likely causing avoidable distress: boredom and frustration.

Long periods left in his room

34. The records indicate Mr X was frequently in the lounge and communal areas for meals and in the evenings. There is no fault.

The call bell being left out of Mr X’s reach

35. One entry in the records indicates Mr X could not use the call bell. This is wrong because I have seen call bell records for one month which indicate he used it regularly. Mrs X’s photos indicate the call bell was out of reach on the occasions the photos were taken. This was fault. Care was not in line with Regulation 12. The furniture and/or TV should have been positioned to enable Mr X to have access to the call bell. It caused avoidable distress.

Providing inappropriate food

36. The Care Home kept records of Mr X’s food. They indicate he was given a normal diet in line with his care plan. The records indicate a stable weight pattern. Care was in line with Regulation 14 and there is no fault.

A failure to act on the advice of a physiotherapist

37. There is no record of staff supported Mr X to walk and this is a matter Mrs X raised frequently. Care was not in line with his care plan and this was a failure to promote Mr X’s independence and mobility which wasn’t in line with Regulations 9 or 12. This was fault causing avoidable distress and a loss of opportunity.

Infrequent showers (once a week)

38. The care plans said Mr X liked to have a shower daily. The records indicate he had one once or twice a week at most. Care was not in line with his stated preferences or with Regulation 9 and this was fault causing avoidable distress and a lack of control over his own hygiene.

Putting Mr X to bed at 7pm

39. Mr X’s care plans said night staff were to ask him when he wanted to go to bed. There is not enough detail in the records for me to conclude fault.

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Agreed Action

40. 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 Care Home and make the following recommendations to the Council.
41. Within one month of my final decision, the Council has agreed to complete the following actions:
• A written apology to Mr and Mrs X. 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.
• A payment of £350 to Mr X to reflect the avoidable distress caused by the failings in care described in the previous section.
• A payment of £150 to Mrs X for her avoidable distress at witnessing Mr X receiving poor care.
• Provision of a written record of a quality monitoring visit by the Quality Assurance Team. The report should set out an action plan for improvements to the Care Home’s service in the areas where I have identified fault.
42. The Council should provide us with evidence it has complied with the above actions.

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Decision

43. I find fault causing injustice. The Council has agreed actions to remedy the injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman