Summary: The Care Provider failed to update Mrs Y’s care plan to reflect a change in her care needs around continence. There was also a failure to ensure Mrs Y saw a chiropodist regularly. This caused avoidable distress for which the Care Provider has apologised, completed staff training and introduced a new policy around continence care. This action is appropriate and so there is no need for us to make any recommendations. We did not uphold complaints about poor oral care or a failure to obtain treatment for a urine infection.

The complaint

1. Mrs X complained about her mother Mrs Y’s care in Moreton Hill Care Centre (the Care Home). Barchester Healthcare Homes Ltd (the Care Provider) owns and manages the Care Home. Mrs X complained about:
1. Poor oral care which led to Mrs Y being unable to eat and requiring urgent dental treatment on admission to the new care home
2. Failure to ensure Mrs Y received treatment for a urine infection
3. Failure to ensure Mrs Y had regular footcare requiring urgent treatment by a chiropodist in the new care home
4. Poor communication and rudeness
5. Poor personal hygiene, soiled clothes and bad odour.
6. Another person’s medication being sent with Mrs Y to the new care home.
2. Mrs X said this caused avoidable 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 an injustice, or could have caused injustice, to the person affected. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
4. We provide a free service and use public money carefully. We do not start or continue an investigation if we decide:

• any injustice is not significant enough to justify our involvement, or
• we could not add to any previous investigation by the organisation, or
• there is no worthwhile outcome achievable by our investigation.

(Local Government Act 1974, section 24A(6), as amended, section 34(B))

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(1), as amended)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I have and have not investigated

7. I have investigated complaints (a) (b) and (c).
8. I have not investigated the other complaints because:
• Complaints (d) and (f) did not cause a significant injustice
• It is not practicable to investigate complaint (e).

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How I considered this complaint

9. I considered evidence provided by Mrs X, the Care Provider and the current care home as well as relevant law, policy and guidance.
10. Mrs X and the Care Provider 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

11. 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. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) We consider the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
12. 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.
13. 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.

What happened

14. Mrs Y had dementia and lived in the Care Home between 2022 and June 2024, when she moved to a different care home. Mrs X has power of attorney to manage Mrs Y’s finances and she arranged and paid for Mrs Y’s care in the Care Home.
15. The Care Provider told me Mrs Y last saw a dentist in August 2023, but it could not locate the care record to confirm this.
16. The Care Provider told me Mrs Y last saw a chiropodist in January 2024. This was invoiced in February, but the practitioner was external and maintained their own clinical record. The Care Provider also told me it could not explain why the chiropodist stopped seeing Mrs Y after January 2024 and the practitioner no longer provided services to the Care Home.
17. Mrs Y’s oral health assessment in May 2024 said she was at low risk. If she scored two points for any category, the Care Home would have needed to arrange a dental appointment. The assessment scored Mrs Y at one overall. Assessment included examination of her lips, tongue, gums, saliva, oral cleanliness and pain, recording no concerns. She had natural teeth and one to three decayed, broken or worn-down teeth. She was not in any pain.
18. The Care Provider’s care plans said:
• Mrs Y could communicate verbally and enjoyed engaging in conversation
• She had low needs around personal care, needed one member of staff to support her with personal hygiene and dressing. She would get up and dressed independently but would forget to wash or brush her teeth and so staff needed to prompt her. She needed support to wash hard to reach areas and with putting on underwear and socks.
• She liked to brush her own teeth
• She quite liked a bath or shower, but also liked a flannel wash
• The chiropodist maintained her foot and toenail health and visited every six to eight weeks.
• She could say when she was in pain.
19. The Care Provider kept detailed daily notes of the care and support it provided. I have looked at the records for the final few weeks of Mrs Y’s stay. The notes said Mrs Y was independently brushing her teeth, she mostly had a body wash or shower each day, but on occasions would decline. There was no note of Mrs Y expressing any pain in her mouth or feet and she was said to have been eating and drinking well. The general picture was of no concerns. Mrs Y was noted to use the toilet independently on the majority of occasions. A couple of entries said Mrs Y had needed assistance from staff after incontinence of urine.
20. Mrs Y moved to a new care home on 7 June 2024. The deputy manager told me she noted:
• Mrs Y’s toenails needed cutting on 7 June.
• Mrs Y told her it hurt when she passed urine on 8 June
• Mrs Y was prescribed a three-day course of antibiotics for a urine infection on 10 June
• Mrs Y had a tooth extracted on 24 June. (The new care home has proved me with a copy of an invoice to confirm this)
• Mrs Y saw a chiropodist on 2 July and had her toenails cut
• There were no photos of Mrs Y’s feet or teeth on arrival to the new home.
21. Mrs X used the Care Provider’s complaint procedure. She received three complaint responses. There were also email exchanges, a phone call and in-person meeting from a senior member of staff and correspondence with the local MP. I have summarised the Care Provider’s responses below:
• There were no concerns noted about Mrs Y’s teeth or oral health
• There was a change in Mrs Y’s needs around continence and this was not reflected in her care plan. The change should have been reported to healthcare providers. Staff would be doing refresher training around this
• There was no sign of any decline in Mrs Y’s health that would have indicated a urine infection. She was eating and drinking and appeared to be comfortable
• It accepted Mrs Y had not seen a chiropodist for several months and this was not in line with her care plan. It was sorry for this. But it did not see an ingrowing toenail.
22. The Care Provider told me:
• A senior manager had visited the Care Home with a clinician following Mrs X’s complaint. They provided training to staff on completing and recording accurate and up-to-date care plans
• It implemented a new continence care policy shortly after Mrs Y left the Care Home and staff received guidance on this.

Findings

Poor oral care which led to Mrs Y being unable to eat and requiring urgent dental treatment on admission to the new care home

23. The Care Provider’s records do not indicate Mrs Y had any pain or there were any concerns noted when she left the Care Home. Its oral assessment completed in May is detailed and descriptive and indicates Mrs Y was low risk. The records indicate attention was paid to Mrs Y’s oral care and this is good practice.
24. The new care home has not provided any evidence indicating Mrs Y had an urgent need for dental treatment. She had an extraction three weeks after she moved. A gap of three weeks does not indicate any urgent need for dental treatment. There is no fault by the Care Provider.

Failure to ensure Mrs Y received treatment for a urine infection

25. Mrs Y was able to express pain. The Care Provider’s records do not indicate she said she was in any pain or discomfort; nor did staff note any concerns about Mrs Y’s general health in the days before she left the Care Home. The new care home did not provide me with any evidence indicating any concerns about Mrs Y’s wellbeing until the the day after she left the Care Home (8 June). And Mrs Y did not start on any treatment for a urine infection until the 10 June which was three days into her residence at the new care home. This indicates a likelihood that the urine infection did not become symptomatic until after Mrs Y moved. There is no fault by the Care Provider.
26. The Care Provider noted in its complaint response that Mrs Y’s needs had changed around continence and it should have updated her care plans to reflect the change in need. Her care was not person-centred in that regard which was fault. It has apologised and provided staff with training and this is an appropriate remedy.

Failure to ensure Mrs Y had regular footcare requiring urgent treatment by a chiropodist in the new care home

27. There is fault by the Care Provider which it accepted in its complaint response. It did not ensure Mrs Y received regular footcare between February and June 2024 in line with her care plan. Staff did not work with healthcare professionals or provide person-centred care. It is likely Mrs Y’s toenails would have been long and have required cutting. There is not enough evidence to conclude she had an ingrowing nail and there is no record of pain or discomfort. So I do not conclude Mrs Y experienced significant distress. The Care Provider accepted fault and apologised. This is an appropriate remedy.

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Decision

28. I find fault causing injustice. The Care Provider has already taken appropriate action to remedy the injustice.

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Investigator's decision on behalf of the Ombudsman