Summary: We have not found fault in the way the care home provided personal care to Ms C. However, there were two incidents witnessed by Ms C’s family and friends which were not properly recorded and, in one of the incidents, care was not provided in line with the care plan.

The complaint

1. Mr B complains on behalf of his mother, Ms C, who has died. Mr B complains about the Dora Rose care home in Milford, Stafford.
2. He says the Home failed to provide appropriate care to Ms C, particularly in relation to personal care. He says, as a result, Ms C was left unwashed and unkempt. He also complains about two incidents when he says the Home’s staff mistreated Ms C.

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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 making the complaint. I have used the term fault to describe such actions. If they have caused a significant injustice or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(3 and 4) as amended)
4. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Loc.al Government Act 1974, section 30(1B) and 34H(1), as amended)

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How I considered this complaint

5. I considered evidence provided by Mr B and the Home as well as relevant law, policy and guidance.
6. Mr B and the Home had an opportunity to comment on my draft decision. I considered any comments before making a final decision.
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Law, guidance and policy

8. 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.
9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards which says;
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• Service users must be treated with dignity and respect (regulation 10).
• The care and treatment must be provided in a safe way for service users. (regulation 12).
• Any complaint must be investigated and necessary and appropriate action must be taken in response to any failure identified (regulation 16).
• The Home must, as far as is reasonably practicable, ensure that service users are able to make decisions about their care or treatment (regulation 11).
• The Home must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17)

What happened

10. Ms C was an older woman who moved into the Home in October 2024.
11. Ms C had Alzheimer’s disease and her care plan said the following.
• In terms of communication, Ms C could answer simple questions, but struggled to express more complex needs or emotions which could lead to frustration or agitation.
• The plan set out detailed guidance on how staff should support Ms C’s communication using, among other things, visual and verbal cues, body language interpreting patterns of behaviour and providing reassurance.
• Ms C was occasionally incontinent of urine and bowels and wore incontinence pads. Staff had to support Ms C in continence care but Ms C may resist staff support. She was at risk of urinary tract infections so staff had to monitor this.
• Ms C was at high risk of falls. She could mobilise with a wheelie trolley but often forgot to use this. Staff should encourage her to use the wheelie trolley Ms C had a sensor mat by the bed which alerted staff when she got out of bed and enabled staff to monitor Ms C when she was mobilising.
• Ms C could be verbally and physically aggressive towards staff when staff tried to support her, particularly in personal care. This could place Ms C at risk of harm, for example, by remaining in soiled or wet clothing. This necessitated staff taking actions that were in Ms C’s best interest, even when these actions caused her distress. There was detailed guidance on how staff should interact with Ms C when she was aggressive using de-escalation techniques.
12. Ms C moved to the Home’s memory unit on 29 March 2025 as it was decided that her needs would be better met there. The memory unit is a unit that is designed to support people with cognitive impairment.

Complaint – April 2025

13. Mr B and his sister, Ms D, complained to the Home in April 2025 and said:
• Things went reasonably well during the first 6 months of Ms C’s stay although there was an incident when Ms C had a fall and Ms D found Ms C crawling on the floor, without any person present supervising or supporting her.
• Ms C moved to the memory unit on 29/30 March and after that move, the standard of care deteriorated. Mr B said the Home failed to provide appropriate personal care to Ms C. She was frequently left unwashed or showered with dirty hair, her nails had not been cleaned or cut and faeces was found under her nails. Ms D had to wash Ms C’s hair and cut her nails on more than one occasion as it had not been done.
• ‘To say she is left unwashed because she refuses to let the so-called carers on that floor get near her and tries to scratch them is laughable. Your staff should be trained to deal with situations like this, not just walk away and let her fester in her own filth. This, in my opinion, is a clear case of negligence.’
• There was an incident on 13 April 2025 when Ms C’s friends visited Ms C and the friends said they could hear the care workers shouting at Ms C who was clearly distressed. One of the friends said the care worker ‘roughly cleaned mum’s bottom and legs which caused her more pain and distress.’
• The care worker could not find Ms C’s clean socks and ‘appeared to lose patience, pulled the bed out and started throwing mother’s shoes and slippers out of the way. Mum asked her to stop but this person ignored her and carried on, clearly unable to deal with the situation in a calm and sympathetic manner.’
• Ms C had a habit of throwing things out of the window and she had broken one of the restrainers on the window which stopped the window from being opened fully. The window had not been repaired.
• There was an incident on 14 April 2025 when Ms D visited Ms C and was unable to access Ms C’s bedroom. Ms D said Ms C was refusing to get out of bed, was sobbing and saying ‘they are trying to kill me.’

Complaint response – May 2025

14. The Home responded to the complaint in May 2025 and said the following.
• In response to the complaint when Ms C had a fall, the Home said that ‘the advice of the paramedics was sought.’
• ‘I understand that it was upsetting for your mother to be left and she was with a member of staff who was attempting to keep her calm.’
• There was a long wait for the paramedics to arrive and the manager then arrived on her shift and conducted a clinical overview to ascertain if Ms C had any injuries. This was undertaken while Ms D was present.
• The Home acknowledged that Ms C sometimes became extremely distressed when she was supported with personal care. Ms C would lash out and strike staff. The Home discussed these concerns with Ms C’s GP. The Home’s staff were trained to support residents who were resistant to care and who became distressed during care. The Home also made a referral to the Mental Health Team (MHT) and the MHT carried out a full assessment on 16 May 2025.
• Care staff did not cut toenails as this was completed by qualified chiropodist. The chiropodist last saw Ms C on 28 March. The chiropodist visited every six to eight weeks.
• The Home understood that it was sometimes difficult to provide personal care to Ms C. And it was true that on occasion Ms D had to wash Ms C’s hair and cut her nails.
• The records showed that Ms D washed Ms C’s hair on 13 April 2025. Multiple attempts had been made earlier that day to encourage Ms C to have a bath or shower which she had refused. She accepted to have her face washed, her hair brushed, pad changed and clothes changed. This was explained to Ms D who then washed Ms C’s hair.
• ‘I have spoken to the carer who supported your mother on this occasion and she has provided an explanation, confirming that your mother was extremely distressed and did not wish to be supported to change her clothing. She was shouting and had lashed out at the staff member. In addition, they have stated that they do not feel that care was provided in a rough manner however, this has been discussed with the staff member.’
• ‘I would like to apologise for any distress this may have caused your mother’s visitors.'
• In response to the complaint that the care worker had lost patience and was throwing Ms C’s shoes and slippers out of the way, the Home said: ‘I have spoken to the staff on duty that day and they have apologised if it was felt that they were perceived to behave in a manner that was unprofessional and have reflected upon their actions.’
• In response to the complaint about the window, the manager said that the windows at the Home had restrictors in place and these were reviewed each month so that the window could open but not too much. There had been no recent repairs or replacement of any window restrictors at the Home.
• In terms of the incident on 14 April 2025 the Home acknowledged that the door was locked from the inside. The Home had disabled the thumb turn lock of Ms C’s door following the complaint.
15. Mr B also took his complaint to the CQC on 14 April. I will not repeat the complaint or the Home’s response as they are similar to what was stated above. However, the relevant points are that Mr B said the incident witnessed by the friends happened on the day before (13 April). In terms of the incident on 13 April, the Home said: ‘Staff do not recall any person being in distress during a visit.’

The Ombudsman’s investigation

16. I asked the Home to send me all of Ms C’s records from 29 March 2025 to 16 April 2025. The reason for this was two-fold. The timescale included the dates when the incidents occurred (13 and 14 April) so this would allow a closer investigation of those incidents. I also wanted to see how the day-to-day care was provided as Mr B’s complaint was that the Home neglected Ms C’s personal care needs.
17. The daily records showed the following. The Home’s record keeping was, generally speaking, good. There were detailed notes of all the actions taken in terms of personal care, washing, continence care, nutrition and hydration, social stimulation and so on. When there was an incident when Ms C became upset or displayed any behaviour, staff filled in an ABC (antecedent, behaviour, consequence) record.
18. The notes showed that staff offered personal care including a shower or wash to Ms C every day but Ms C refused this frequently. When Ms C refused, staff tried again several times later in the day. The records showed that Ms C was unsettled following her move to the memory unit and became very upset by offers of personal care. There were records of Ms C verbally abusing staff and trying to hit or scratch staff.
19. The daily records showed that Ms C had a shower on 30 March 2025. She refused offers of washing on 1 April all day and two care workers then assisted her with a wash, in her best interests. The records said Ms C abused the staff verbally and physically while the wash took place.
20. On 2 April 2025 Ms C refused offers of showers or a wash and it was decided that the GP should review Ms C during the next ward round. Ms C continued to refuse showers in the following days but accepted a hair wash from Ms D on 5 April. Ms C had a shower on 6 April.
21. On 7 April, the records said Ms C threw her sensor mat through the window and ‘now it’s broken’. The record said it needed to be repaired but it was not clear whether the sensor mat or the window needed to be repaired.
22. Ms C had a medical visit on 9 April and her medication was reviewed. It was then agreed that Ms C would be discussed at the next multi-disciplinary team meeting.
23. Ms C was found on the floor in her bedroom on 12 April. The nurse carried out a full check of Ms C and said Ms C could be returned to bed. Ms C had no injuries apart from a small skin tear to the left cheek. A body map was completed. A falls risk assessment was completed. The family was informed. Later in the day Ms C accepted personal care including a wash.
24. On 13 April, Ms C refused assistance in personal care and a shower or wash. The record said Ms C was unsettled during the day, the family visited and Ms D raised a concern about Ms C’s hair. Staff explained that they tried to give Ms C a shower in the morning but she refused. Ms D washed Ms C’s hair.
25. On 14 April the Home entered an ABC record that that Ms C was in her room ‘Antecedent: she was in the room, we went to her personal care, found floor is wet, she is also wet, asked for shower, but she refused and got aggressive. Behaviour: she got aggressive and she was physically and verbally abusive. But in her best interests, we managed to give her shower. Consequence: she is settled now in comfy chair in her room.’
26. A later record said that Ms D visited on 14 April and the record said: ‘spent her day in bedroom, daughter visited her today, she locked her room once today when daughter came to visit her.’
27. On 15 April Ms C was found wet again and refused a shower but a shower was given in her best interests. An ABC record was completed. Her nails were cleaned.
28. On the same day the nurse contacted the MHT and asked for an urgent review of Ms C as Ms C had a recent decline of her dementia and her mental health. The Home also requested a medical visit for Ms C.
29. The nurse carried out the medical visit on 16 April. The reasons for the visit were to review one of Ms C’s medical conditions, her refusal to take medication and her resistance to staff in maintaining her hygiene. Blood and urine tests were taken and a continence review was requested. The plan was to proceed to covert medication which required the GP’s authorisation and would be added to the DoLS authorisation.
30. The Mental Health Team’s team leader visited Ms C on 16 May 2025. Ms D was present during the visit.
31. The Home explained its concerns about Ms C’s refusal of personal care and medication and Ms C’s distress and aggressiveness towards staff. The Home explained that its approach had been to offer constant reassurance, offer choices and promote independence. If care was refused, then staff allowed Ms C time and tried again.
32. The Home said staff had made best interest decisions to go ahead with personal care on occasions, but Ms C had become very distressed although staff had offered lots of reassurance. The MHT leader said the Home’s staff were doing the right thing. The MHT leader suggested an action plan which included a proposed change in Ms C’s medication, a urine test to rule out any infection and ongoing liaison between the Home, the MHT and the GP.
33. During the two weeks I checked, Ms C’s fingernails were cleaned on 30 March and on 6, 7, 8, 9 and 11 April. The nails were trimmed on 9 April.
34. Mr B also complained about a fall that happened before Ms C moved to the memory unit but he did not say when this fall happened and the Home’s response also did not include a date.
35. The Home checked its records and said Ms C had a fall on 8 February 2025 so the Home sent me the records relating to that fall. The incident report noted that Ms C was found on the floor and Ms C had pressed the emergency button. Ms C said she had hit her head and the nurse noted swelling to the right side of the head. Ms C complained of back and hip pain and an ambulance was called. Ms D was informed.

Analysis

36. Mr B’s main complaint was that there was ‘negligence’ in the Home’s care of Ms C, particularly in personal care such as washing. He said Ms C was left in an unwashed state and he did not accept that Ms C’s resistance to personal care was either an explanation or an excuse.
37. I have looked at the records for the first two weeks when Ms C moved to the memory unit and there were times when Ms C was not washed so I accept Mr B’s evidence in this respect. However, that does not mean I can say there was fault in the Home’s actions.
38. I note the following. Ms C was frequently distressed following her move to the memory unit and would often refuse any offer of personal care.
39. The Home’s record keeping in this respect was good and showed that the staff repeatedly offered Ms C a wash or shower even if she refused. The Home’s care plan provided detailed guidance to staff in how they should address refusals and how they could support Ms C when she was distressed. I find no fault in that respect.
40. I note that the care plan allowed staff to proceed with a wash even if Ms C said she did not want a wash, but this should only be done in her best interest and staff could not use force. I note that the staff made the best interest decision to give Ms C shower even though she refused on a few occasions. The records showed Ms C was distressed and was described as verbally and physically abusive in the documents. The best interest decision to go ahead with a shower was often done when Ms C was wet with urine so the Home felt it was more important to get Ms C clean even though this may upset Ms C.
41. I also note that the Home liaised with the GP and held multi-disciplinary meetings about how to best support Ms C because of the concerns that personal care caused her distress. I note that the Home made a referral to the MHT and the MHT lead said that the Home’s approach was correct and suggested further actions by the different agencies to support Ms C.
42. So overall, I find no fault in the way the Home provided personal care to Ms C. The Home took all the appropriate actions. The Home was in a difficult position as it wanted to support Ms C in showers and washing, but also did not want add to her distress. It had to make a best interest decision on a daily basis whether it was to decide whether to impose a wash and cause additional distress or allow Ms C to go without a wash that day, but be less distressed.
43. I accept completely that it may have been distressing to the family to see Ms C unwashed on occasion, but overall I cannot say there was fault in the Home’s approach.
44. In terms of the complaints relating to specific incidents, it was difficult to investigate those as the dates and the documents were not clear. In terms of the undated incident when Ms C had a fall, the Home sent me an incident report from February 2025. However, there was no mention in this report of Ms D finding Ms C or Ms C being unsupervised so I am not sure whether this was the correct date.
45. There is no ABC record for 13 April (the date of the incident which Ms C’s friends reported) and no mention of a visit by Ms C’s friends on that day. I am of the view that the Home should have filled in an ABC record or kept some record of the incident described by Ms C’s friends so there is fault in the failure to do so.
46. As there is no record of any incident happening on 13 April, I have relied on the Home’s evidence as set out in the complaint response dated 23 May 2025 and the evidence of Ms C’s friends. The Home said the care worker did not ‘feel that care was provided in a rough manner, however this has been discussed with the staff’. The staff member apologised and ‘reflected upon their actions…if it was felt that they were perceived to behave in a manner that was unprofessional.’
47. So although this was oddly worded, there was some acknowledgment by the Home that the care worker’s actions were not in line with the care plan which is also what Ms C’s friends observed. I accept the evidence of Ms C’s friends, on the balance of probabilities. The friends said the care worker shouted at Ms C and that the care worker lost patience and threw Ms C’s items on the floor. That was not in line Ms C’s care plan and was fault.
48. In terms of Ms C’s bedroom window, it is not clear from the record on 7 April whether the mat or the window needed repairing, but clearly Ms C was able to open the window wide enough to throw the sensor mat through the window.
49. There is an ABC record for 14 April, but it does not relate to the incident described by Ms D. Ms D said she heard Ms C inside the bedroom ‘refusing to get out’ of bed and Ms C was sobbing. This suggests that there was a care worker in the room with Ms C, but the record suggested that Ms C had locked herself into the bedroom, presumably on her own which contradicts Ms D’s account. The Home’s complaint response did not say who locked the door although it acknowledged the door had been locked. So it is difficult to say what happened but there should have been a better record of the incident.
50. So in conclusion, overall I find no fault in the Home’s support in personal care for Ms D, but there were two incidents, witnessed by family and friends, where the Home failed to keep proper records and, in one of the incidents the care was not provided in line with the care plan, causing distress to Ms D and the family. The lack of record keeping also means there will always be uncertainty on what actually happened.

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Action

51. I recommend the Home apologises to the family for the fault I have identified within one month of the final decision.

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Decision

52. I have completed my investigation and have found that the Home’s actions have caused an injustice. I have made recommendations to remedy injustice but the Home has not yet agreed to carry out the remedy.

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Investigator's decision on behalf of the Ombudsman