Summary: Ms D complains about poor care provided to her late father, Mr F, by The Cambridge Nursing Centre. Mr F’s care there was funded by both the NHS and Cambridgeshire County Council. The Ombudsmen have upheld parts of Ms D’s complaint relating to falls, communication, capacity assessment, end of life care and loss of possessions. We have not upheld other elements of the complaint. The Council and The Cambridge Nursing Centre accept our recommendations, so we have completed our investigation.

The complaint

1. The complainant, whom I shall call Ms D, complains that between 10 April and 23 September 2018, The Cambridge Nursing Centre (the Home) provided poor care to her late father Mr F. Cambridgeshire County Council (the Council) and the NHS both funded the Home to care for Mr F.
2. Ms D says the poor care included:
• flaws in falls prevention, post falls management and reporting;
• poor communication with family and other organisations involved in managing Mr F’s care;
• inappropriate management of Mr F’s confusion/dementia and capacity assessment;
• inappropriate management of Mr F’s end of life care;
• transferring Mr F to a non-pressure relieving chair in a communal area at night; and
• poor response to loss of possessions.
3. Ms D says that this caused Mr F avoidable distress and discomfort at the end of his life. She says it also caused her distress and meant she was put to avoidable time and trouble.
4. Ms D would like an acknowledgement of what has gone wrong and service improvements.
5. Ms D also complained about Council’s handling of financial assessments for
   Mr F’s contributions to the cost of his care.

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What I have investigated

6. I have investigated the complaints relating to the Home’s care of Mr F. I have explained at the end of this statement why I have not investigated the complaint about the Council’s handling of financial assessments.

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The Ombudsmen’s role and powers

7. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
8. When investigating complaints, if there is a conflict of evidence, the Ombudsmen may make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
9. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
10. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
11. The Ombudsmen may investigate, and question the merits of, action taken in the exercise of clinical judgement.
12. The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start or continue with an investigation if they believe it is unlikely they could add to any previous investigation by the bodies. (Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)
13. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)
14. 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

15. I have considered the following evidence:
• information Ms D has provided in writing and by telephone;
• written comments and copies of records from the Home and the Council;
• relevant law and guidance; and
• specialist advice from a registered nurse with experience in the care of older people, who is independent of the Home and the Council.
16. Ms D, the Council and the Home have had an opportunity to comment on a draft version of this decision.

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What I found

Background summary

17. Mr F went into hospital in March 2018 following a fall. He had recent weight loss and his dementia became more apparent during his hospital admission. He also had a chest infection and an infection of the gall bladder area which needed surgery and a drain with catheter. He was discharged from hospital to the Home in April 2018. Mr F stayed in the Home, other than when he was re-admitted to hospital, between April and September 2018. His stay there was at times funded by the Council and at times by the NHS. Mr F died at the Home on 23 September 2018 following a significant decline in his health.
18. Mr F’s daughter Ms D complains that his care at the Home was poor.

A – Falls

Relevant law and guidance

19. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations) set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards which care must never fall below.
20. I have listed the Regulations relevant to falls prevention and management below.
• Regulation 9 says that people must get care and treatment that is appropriate, meets their needs and reflects their preferences.
• Regulation 10 says care providers must treat their service users with respect and dignity at all times.
• Regulation 12 says that providers must provide care and treatment in a safe way. This includes doing risk assessments, taking all reasonable steps to manage risks and protect service users’ health and safety, making sure staff have the right skills and qualifications to keep people safe, and ensuring equipment is safe.
21. In June 2013, The National Institute for Health and Care Excellence (NICE) issued the clinical guideline: Falls in older people: assessing risk and prevention (CG161). This notes that:
• people over the age of 65 have the highest risk of falling;
• staff should identify and address individual risk factors that can be treated or improved; and
• after treatment for an injury caused by a fall, older people should be offered a multidisciplinary assessment to identify future risk and individual intervention.

My analysis

22. The Home completed a pre-admission assessment which indicated Mr F was at risk of falls on 9 April 2018. An admission assessment dated 20 April 2018 confirmed this. The Home did a falls risk assessment on the same day and this said he was at increased risk of falls because he:
• had a history of falling;
• was unsteady when walking because he disliked supervision and lifted his walking frame when walking;
• had lost weight, had a cognitive impairment and felt he was more able to look after himself that he really was;
• did not always use his frame when going to the toilet;
• had poor hearing.
23. Throughout his stay at the Home, the Home assessed Mr F as being at high risk of falls.
24. Ms D is concerned that the Home did not carry out a falls risk assessment as soon as he moved into the Home from hospital. While this is the case, Mr F did not have any falls until August 2018 and so any delay in carrying out the risk assessment did not cause him harm.
25. I have found no faults in the falls risk assessment the Home carried out on
    20 April 2018 because it considered relevant matters and, in accordance with guidance, identified Mr F as being at risk of falls.
26. Mr F's falls care and support plan dated 20 April 2018 says:
• Mr F had variable understanding of his risk of falling, used furniture for balance in his room and a frame outside the room when prompted;
• Mr F was tired most of the time, preferred spending his time lying on his bed moving only to use the toilet and was not taking steps to improve his abilities;
• there was a high risk of falling as a result of drowsiness from medication (lorazepam);
• Mr F had a sensor mat and overnight crash mat in his room;
• external advice was for Mr F to use his frame to keep his balance while walking; eat and drink well, prepare to stand to help stay steady, and to wear well fitting shoes; and
• Mr F’s stressed or angry response to being prompted for personal care could lead to risk of falling if rising or walking when agitated, so staff needed to withdraw if Mr F became angry.
27. Mr F’s mobility care and support plan of 20 April 2018 says Mr F should use a walking frame or wheelchair to get about, with the supervision of one person to help keep him safe.
28. Mr F’s safe environment care and support plan dated 20 April 2018 said that he was aware of some limitations and could make good choices but would then forget and revert to previous poor approaches. It recommended he used a walking frame and staff removed items from his room that could pose risks, for example furniture with wheels. The reviews for this care plan, dated May, July, August and September, said Mr F lacked insight into risks and did not call or wait for help.
29. The way the falls care plan form is set out does not state clearly what the Home’s plan was to prevent Mr F falling and how the Home would deal with falls if they did happen. However, Mr F’s falls care plan has a section for external advice which contains what is essentially a plan aimed at preventing falls. I therefore consider that:
• any faults with the form layout did not cause Mr F an injustice because the information on the form amounts to a care plan; and
• there were no other faults in falls care planning.
30. The Home may consider reviewing and amending its standard falls care plan form to prevent its current format causing problems in the future.
31. Daily care records indicate Mr F would sometimes try to walk without equipment or help and would get agitated. There are also many records of Mr F refusing food and drinks and staff encouraging him to eat or drink, or offering alternatives. Records also indicate staff would follow the falls care and mobility plans by helping him walk or offering to move him in a wheelchair and by withdrawing to try to reduce his agitation.
32. Although Mr F was supposed to have a sensor mat in his room from April 2018, daily care notes of 4 August indicate that it was not in place around the time of the fall in August. Daily care notes also refer to his call bell being “faulty again” on
    23 August. Failing to have a working sensor mat and call bell in Mr F’s room despite assessing him as needing a mat and help with moving around was fault. Other than the faults with the falls mat and call bell, the Home followed the falls care plan.
33. While following the care plan could minimise the risk of falls, it could not eliminate the risk. Mr F’s daily care records and the Home’s Datix system (a computerised record of incidents affecting residents’ safety) record two falls. These are summarised below.
• On 2 August 2018, staff found Mr F kneeling on the toilet floor in the early evening. He had a 1 x 1.5 cm skin tear on his left elbow. Records say staff observed Mr F’s vital signs, cleaned and dressed his wound and checked him hourly overnight.
• On 3 September 2018, a carer working in a nearby room heard a fall and found Mr F on the floor, face down and bleeding from a cut on his right elbow. He also had a small tear on his elbow and a graze on his back. Notes say staff gave first aid and called 999. The ambulance service did not consider it needed to see Mr F urgently because he was conscious and had no signs of head or neck injury. The Home’s records say the ambulance service told staff they could help Mr F back to bed if he wanted to go back to bed, and that staff did this when Mr F became restless. A paramedic attended about four hours later to examine Mr F and treat his wounds.
34. I consider that:
• the Home recorded the falls in accordance with national guidance and without fault;
• the daily care records indicate the Home took appropriate action in response to Mr F’s falls; and
• while the records indicate nurses took neurological observations [a collection of information on a person’s nervous system] after the fall of 3 September 2018, there are inadequate records of what those observations were. However, this did not cause Mr F an injustice because he was seen and treated by a paramedic, who decided he did not need to go into hospital. I have made recommendations to prevent similar fault causing problems for other residents.
35. The Home’s records say it should have reviewed Mr F’s care plans at least once a month. Records indicate it reviewed the falls care plan in May, August and September but not in June or July. The Home reviewed Mr F’s falls care plan during the morning of 2 August, he had the first recorded fall in the evening of that day. However, it did not review the care plan after the fall. The Home also failed to carry out a monthly review of Mr F’s safe environment care plan in June 2018. Not reviewing Mr F’s care plans at least monthly and failing to review the falls care plan in response to the fall of 2 August were faults.
36. We cannot say now whether Mr F’s falls could have been avoided had there been no fault with care plan reviews and equipment. This is because:
• records indicate Mr F often insisted on walking without his frame or staff supervision;
• records also indicate that he sometimes had little insight into his falls risk and could become very angry if he perceived care home staff were interfering with him; and
• not all falls can be prevented. Attempting to do so could have led to unreasonable restrictions on Mr F’s freedom of movement, or provoked an angry response from Mr F that could also have resulted in a fall.
37. However, the faults with care plan reviews and equipment have led to missed opportunities to reduce the risk of Mr F falling. To prevent similar faults causing problems for others, I have made recommendations below.
38. The Nursing and Midwifery Council (NMC) Code says that nurses should make timely and appropriate referrals to other practitioners when it is in a patient’s best interests to do so. NICE guidance says that after a fall which needs treatment for injury, patients should be offered a multidisciplinary assessment to identify future risk and individual intervention. There is no record that the Home and Council did this following Mr F’s fall of 3 September 2018 when he needed treatment for an injury above his eyebrow. This was fault but did not cause Mr F an injustice because the Council and Home put 1:1 supervision in place for Mr F and Mr F had no further falls. I have made recommendations to prevent similar fault causing problems for other residents.

B – Communication

39. Ms D says the Home’s communication with family and other organisations involved in managing Mr F’s care was poor.
40. I have reviewed the Home’s records of communication with professionals and family and Mr F’s daily care records. Those records indicate the communication around Mr F’s care:
• was frequent and clear enough; and
• contained relevant information.
41. The information I have seen indicates the Home contacted professionals when the need arose, for example calling Mr F’s GP about illnesses or the ambulance service when Mr F fell and hit his head.
42. The Home’s records also show that in late April 2018, the Home took part in a multi-disciplinary meeting to assess whether he had a need for continuing health care. The record of that meeting, dated 1 May 2018, says Mr F had been referred to the mental health team. The first record of a community psychiatric nurse assessing Mr F is dated 12 July 2018. I consider that:
• the Home should have contacted the mental health team to find out about any previous involvement with Mr F and to chase the referral before July 2018. Not doing so was fault;
• this is the only fault I have identified in the records of the Home’s communication with family and professionals around managing Mr F’s care;
• we cannot say now, even on balance of probability, whether this caused Mr F a problem. This is because we do not know whether the mental health team would have seen Mr F any sooner had the Home chased up an appointment, or whether an earlier appointment would have made a significant difference to Mr F’s welfare.
43. I have addressed the Home’s communication with Ms D about lost possessions separately below.

Management of dementia and capacity assessment

44. Ms D says the Home’s management of Mr F’s dementia and assessment of
    Mr F’s capacity were flawed.
45. The Home says it:
• carried out a pre-admission assessment on 9 April 2018, a day before Mr F’s hospital discharge;
• completed a mental capacity assessment and made a Deprivation of Liberty Safeguards (DoLS) application on 27 April 2018;
• completed risk assessments and care planning regarding his care and support needs;
• implemented a stress and distress plan to direct staff practice;
• made sure staff withdrew for 10-15 minutes if Mr F became distressed;
• monitored Mr F and used behaviour charts to try to identify themes and trends to help plan for specific care and support arrangements; and
• decided Mr F would need extra supervision to prevent falls.
46. In response to our enquiries, the Home has acknowledged there is no evidence of a Best Interests decision regarding confining Mr F to the Home.

Relevant law and guidance

47. The Mental Capacity Act 2005 (the MCA) applies to people who may lack mental capacity to make certain decisions. Section 42 of the MCA provides for a Code of Practice (the Code) which sets out steps organisations should take when considering whether someone lacks mental capacity.
48. Both the MCA and the Code start by presuming individuals have capacity unless there is proof to the contrary. Someone can have capacity and still make unwise decisions.
49. The Code says, at paragraph 2.11, there may be cause for concern if somebody repeatedly makes unwise decisions exposing them to significant risk of harm or exploitation. The Code says this may not necessarily mean the person lacks capacity, but further investigation may be required.
50. The Code says that assessing a person’s capacity to make a decision has two stages, where the assessor has to consider the following.
• Does the person have a temporary or permanent impairment of the mind or brain, or disturbance affecting the way their mind or brain works?
• If so, does that impairment or disturbance mean that the person is unable to make the decision in question when it needs to be made.
51. The Code says that, as part of assessing a person’s ability to make a decision, the assessor should consider whether the person can:
• understand what decision they need to make, and why;
• understand the likely consequences of making or not making the decision;
• understand, retain, use and weigh up the information relevant to this decision; and
• communicate their decision by any means.
52. A key principle of the Mental Capacity Act 2005 is that any act done for, or any decision made on behalf of a person who lacks capacity must be done, or made, in that person’s best interests. Section 4 of the Act provides a checklist of steps that decision-makers must follow to determine what is in a person’s best interests. The decision-maker must also consider if there is a less restrictive option available that can achieve the same outcome.
53. The Deprivation of Liberty Safeguards (DoLS) is an amendment to the Mental Capacity Act 2005 that came into force on 1 April 2009. The safeguards provide legal protection for individuals who lack mental capacity to consent to care or treatment and live in a care home, hospital or supported living accommodation. The DoLS protect people from being deprived of their liberty, unless it is in their best interests and there is no other less restrictive alternative. The legislation sets out the procedure to follow to obtain authorisation to deprive an individual of their liberty. Without authorisation, a deprivation of liberty is unlawful. It is the responsibility of the care home or hospital to ensure that any deprivation of liberty is lawful. The Government issued a DoLS Code of Practice in 2008, to serve as statutory guidance on how DoLS should be applied in practice.
54. There are two types of authorisation: standard and urgent. Standard authorisations are made by the local authority. Urgent authorisations can be made by the care home itself for seven days, pending an application for a standard authorisation or while waiting for a response to a standard authorisation request. In exceptional circumstances, a local authority can extend an urgent authorisation to a maximum of 14 days. Care homes can apply for standard authorisations in advance of a resident moving there, for example as part of the hospital discharge process.
55. The DoLS Code of Practice sets out what a council should do if there is a concern that a person is being deprived of their liberty in a care home without authorisation. In summary, it should bring this to the care home’s attention and ask the care home to request a standard authorisation within an agreed time. If the care home does not do this, the council should assess whether there is an unauthorised deprivation of liberty within seven days.
56. Although Parliament has changed the law relating to DoLS recently, this is the law and guidance that applied at the time of the events Ms D complains of.
57. The following regulations are relevant to the Home’s management of Mr F’s dementia and mental capacity assessments.
• Regulation 11 says that care homes must provide care and treatment with a person’s consent, or in accordance with the Mental Capacity Act and Code of Practice if the person lacks capacity.
• Regulations 9, 10 and 12, which I have detailed above, are also relevant here.
• Regulation 13 says a person must not be deprived of their liberty without lawful authority.
• Regulation 14 says care providers must meet residents’ needs for food and drink. This includes support with eating and drinking, if necessary.

My analysis

58. The Home assessed Mr F before he moved there from hospital and produced care plans on 20 April. The Home did not produce a specific dementia care plan. However, all the other care plans refer to Mr F’s dementia symptoms and how these affected his care needs and daily life. The assessment and care planning relating to dementia care are in accordance with the Nursing and Midwifery Council (NMC) Code. My view is therefore that the Home’s care planning took
    Mr F’s dementia symptoms into account appropriately.
59. The Home produced a Stress and Distress care plan on 10 May, after Mr F had been living there for a few weeks. It said that Mr F would shout at staff if he felt pressured into personal care, or if another resident went into his room and made him feel uncomfortable. It suggested the following ways of dealing with possibly distressing situations:
• staff should prompt Mr F to carry out his own personal care and help him do this in his own time;
• Mr F’s room door should be shut at night and staff agree regular checks with him;
• Mr F needs ‘prompting’, not ‘telling’;
• staff should withdraw from conversations which are challenging for Mr F, and apologise and leave if he becomes angry;
• focus on what he wants to do ‘in the here and now’; and
• distract Mr F with talking to his brother who is also a resident at the Home.
60. I consider it reasonable that the Home would wait until Mr F had settled in before developing a stress and distress care plan. However, I have seen no evidence that the Home reviewed this during Mr F’s stay. This was in my view fault. We cannot say now whether Mr F’s dementia care would have been any different, had the stress and distress care plan been reviewed regularly. I have made recommendations to prevent similar fault causing problems for other residents.
61. Having carefully considered the available records, I consider that the Home managed Mr F’s dementia appropriately in other respects. This is because daily care records indicate that:
• the Home followed Mr F’s care plans including the stress and distress plan;
• Mr F was encouraged to take part in activities but would prefer to spend time in his room, often with visitors or his brother;
• staff encouraged Mr F to eat, drink and move around safely;
• staff checked if he was in pain and gave pain relief;
• the Home took Mr F’s opinions into account and involved his family in his care; and
• after Mr F’s serious fall on 3 September, the Home started to complete behaviour charts. Mr F received 1:1 supervision from 7 September.
62. On 27 April 2018, the Home assessed Mr F’s capacity to decide whether he should be confined on a dementia unit. This was really an assessment of Mr F’s capacity for the purposes of a DoLS authorisation. The assessment says that:
• Mr F has a permanent impairment in the form of dementia;
• Mr F can understand a conversation about the reasons for him staying in the Home, but cannot retain the information and will ask for it again in a short time;
• Mr F cannot recall how limited his personal abilities are and so “cannot project…coping scenarios”;
• Mr F can communicate well.
63. The assessment concluded that it was in Mr F’s best interest to be cared for on a closed unit to reduce his falls risk, so he could receive personal care and nutrition, and possible palliative care.
64. The Home also completed an urgent DoLS authorisation on 27 April 2018. This authorised the Home to deprive Mr F of his liberty (in the closed dementia unit) for seven days. The Council could have extended this authorisation for a further seven days, and/or granted a standard DoLS authorisation following a formal assessment. However, the Council says it has not received any DoLS documents from the Home.
65. The Home acted with fault in:
• not assessing Mr F’s capacity to make decisions about his care and where he wants to live as soon as he moved into the Home;
• not applying to the Council for a DoLS authorisation before or as soon as Mr F moved in, when the seven-day period for the urgent authorisation ended, or when Mr F became subject to continuous 1:1 supervision in September 2018;
• failing to make formal recorded Best Interest decisions regarding Mr F’s care planning.
66. The Council assessed Mr F’s mental capacity to decide on his care arrangements between May and June 2018. It decided he did not have capacity for that decision, and that it would be in his best interests to stay in the Home. As a result of the assessment, the Council was aware that Mr F did not want to stay in the Home but could not leave. The Council was also aware that Mr F was subject to continuous 1:1 supervision from 7 September. The Council would have been aware there was no standard DoLS authorisation in place. The Council acted with fault in not asking the Home to request a DoLS authorisation request at those points.
67. As a result of the faults, Mr F was potentially unlawfully deprived of his liberty for some of his time at the Home. This did not cause him significant harm. This is because, on the available evidence, I consider it more likely than not that
    Mr F would have been subject to the same restrictions and received the same care, if the Home and Council had followed all the necessary steps to comply with the law on deprivation of liberty.
68. I have made recommendations to prevent similar faults causing harm to others.

Management of end of life care

69. Ms D says the Home’s management of Mr F’s end of life care was inappropriate. She is concerned that Mr F did not receive all the medications he needed to relieve his symptoms, and that some medication was injected incorrectly.
70. The Home says it implemented an end of life care plan written in collaboration with Ms D. The arrangements were for Mr F to remain in the Home for his end of life care, monitored by the GP.

Relevant guidance

71. NICE has produced a guideline (NG31) on the care of adults in the last few days of their life. The guideline covers the following:
• recognising that a person is in the last few days of life;
• communication and shared decision making;
• relevant assessments and care planning;
• support with hydration; and
• medication and management of symptoms.
72. The Medication Administration Record (MAR) sheet lists a patient’s medication, the quantity of tablets received, the dose, frequency and time of administration over a four-week period. The pharmacy or GP surgeries usually print the MAR. Home staff sign it acknowledge receipt of medication, to record when they administer it or to record if, for any reason, it is not given.
73. The Nursing and Midwifery (NMC) issued The Code in 2009 (updated 2015). This sets out standards of conduct, performance and ethics for nurses and midwives. It says clear and accurate records should be kept of discussions, assessments, treatment and medicines given, along with how effective these have been.

My analysis

74. Mr F’s GP prescribed anticipatory end of life medications at the end of July 2018. The Home produced an end of life care plan on 3 August 2018, in discussion with Ms D. The GP stopped all non-essential medication on 20 August and reviewed Mr F’s end of life medication prescription on 26 August. The GP advised the Home on 5 September that it could start using the end of life medication when staff see that Mr F is in pain.
75. Mr F declined significantly on 22 September 2018. The Home’s nurses gave him morphine (strong pain relief) on 22 and 23 September. They also gave him Midazolam (used to treat distress and anxiety) on 23 September. The records indicate he received this via subcutaneous injection (injection under the skin), as prescribed.
76. Sometimes people coming to the end of their life may produce more secretions than normal. This can cause distress. Such symptoms can be helped by medication, but the records do not indicate Mr F showed symptoms of excessive secretions or that he received medication to treat this.
77. Some of Ms D’s recollections of what happened during Mr F’s last days differ from the records. Ms D has professional knowledge of nursing practice. She says she saw a nurse inject morphine into a leg muscle rather than under the skin on one occasion. She also says that Mr F was showing clear signs of excessive secretions in the afternoon of 23 September and that after discussion about stock levels, a nurse gave Mr F medication for this. While this clearly conflicts with the Home’s written records, there is not enough supporting evidence for me to uphold Ms D’s complaint on balance of probabilities.
78. The daily care records indicate the carers helped Mr F with personal care when he would permit them to do so and offered him food and drink.
79. Mr F’s end of life care plan was about seven weeks old by the time he entered the last few days of his life. The Home should have reviewed and amended it when Mr F declined on 22 September. Failure to do so was fault but is unlikely to have caused Mr F an injustice. This is because the documentary evidence indicates the Home:
• recognised when Mr F was entering the last few days of life; and
• gave him appropriate personal care and medication, taking account his wishes and preferences at the time.
80. I have made recommendations to prevent failure to review end of life plans causing harm to others.

Transfer to a non-pressure relieving chair

81. Ms D says that the Home transferred Mr F to a non-pressure relieving chair in a communal area at night. The Home says it has found no records of this happening and that it has many different pressure relief cushions placed in all the lounges.
82. I have found no documentary records of the incident Ms D complains of. Ms D’s recollection is clearly at odds with the records. While we have found fault in other areas of the Home’s documentation, there is not enough evidence for us to uphold this part of Ms D’s complaint even on balance of probabilities. I have therefore found no fault in this part of the complaint.

Response to loss of possessions including dentures and pressure relieving cushion

83. Ms D says the Home did not respond appropriately to her concerns about Mr F’s lost possessions, including lost dentures, a lost pressure relieving cushion, and a watch which was kept behind at the Home after Mr F died.
84. The Home says that:
• its contract says residents should insure their possessions when going into the Home;
• it completes an inventory of personal possessions when a person moves in, but this is not updated if residents bring items during their stay;
• it cannot verify that the items Ms D has mentioned were actually in the Home; and
• to try to prevent similar problems happening in the future, it will ask managers to discuss this at the next relatives and residents meeting, to ask residents and relatives to inform staff when they bring new items into the Home.

Relevant law and guidance

85. Regulations 10 and 14, already referenced above, are relevant to personal possessions including dentures in care homes.
86. NICE has published a guideline (NG48) on oral care in care homes. It recommends that care homes:
• carry out oral health assessments for residents and, as part of these, check if residents have full or partial dentures;
• ask residents with dentures whether they are marked or unmarked and offer to help in getting the dentures marked if the resident would like this;
• ensure staff are aware of the importance of residents’ oral health and the possible effect on their health, wellbeing and dignity; and
• ensure staff know how to report any concerns over residents’ oral health and how to respond to a residents’ changing circumstances.

My analysis

87. Ms D says that she wrote an inventory and gave it to the Home when he first moved in, but that the Home did not give her a copy. The Home has not given us a copy in response to our enquiries. Failing to provide a copy of an inventory to residents or, where relevant, their families, is fault as it does not give all parties an opportunity to ensure the inventory is accurate.
88. Mr F’s pre-admission and admission assessments say he had his own teeth in April 2018. Other records support Ms D’s assertion that Mr F had dentures when he moved into the Home. For example, a daily care record for 24 June 2018 mentions a carer cleaning Mr F’s dentures. The initial assessments incorrectly recorded Mr F did not have dentures. This was fault.
89. As a result of these faults, Ms D has been put to unnecessary time and trouble in trying to establish what happened to lost possessions. I have made recommendations below to address this.
90. A daily care record for 1 September 2018 says that Mr F’s daughter approached a carer to complain that Mr F’s dentures were lost. The Home has provided no other records to show what happened to the dentures between then and 23 September, when a daily care record following Mr F’s death includes a note to say that the Home sent his dentures to the funeral directors and kept his wrist watch at the Home to be handed to the family. Ms D has confirmed that the Home did not find the lost dentures and that Mr F wore a spare pair, which was badly fitting, until he died later that month.
91. The Home acted with fault and contrary to Regulations 10 and 14, as well as NICE guidance, in not making a significant and documented effort to:
• check at the start of his residency whether Mr F’s dentures were marked or whether he wanted them marked; and
• search for Mr F’s dentures when Ms D alerted staff that he had lost them.
92. Ms D says her sister brought Mr F’s pressure relieving cushion to the Home some time after he moved in. Neither she nor the Home have a record of this. Ms D says that both she and her sister complained to staff about the loss of the cushion at the time, but she has not kept a record of the date. The records the Home has provided do not contain notes of Ms D and her sister complaining. Given what happened with Mr F’s dentures, I consider it more likely than not that he did have a cushion and that it was lost.
93. The Home’s terms and conditions say that the Home’s insurance covers personal items up to £2,000 per person, excluding items such as jewellery and watches. The terms and conditions do not exclude dentures from the Home’s insurance. They also say the Home will take reasonable precautions to look after personal possessions. I am therefore concerned that the Home is treating the loss of
    Mr F’s dentures and pressure relief cushion in the same way as it might the loss of jewellery. Dentures are necessary to help residents eat, and it can be difficult for residents to get replacements even if they have insurance. It can also be difficult for residents with dementia to get used to wearing dentures again after a long time without them. We would expect the Home to:
• take extra care to prevent loss of or damage to dentures, other prostheses, glasses or personal equipment necessary for a person’s health and safety;
• clearly record reports of loss or damage;
• make every reasonable effort to find such items if they are lost; and
• support residents to get replacements for any such items that are permanently lost or damaged by, for example, facilitating appointments with professionals.
94. I do not consider that speaking to residents and relatives at one meeting will prevent future problems with lost possessions. I have made recommendations below to address this.
95. Ms D says that she was put to unnecessary time, trouble and distress because the Home kept Mr F’s watch rather than allowing it to go with Mr F and the funeral directors. She says this meant that she had to go back into the Home to collect his watch after she had already cleared Mr F’s room. The Home says the funeral directors removed the watch and handed it to the Home for safekeeping and that the unit manager was in a meeting when Ms D came to clear her father’s room, so did not return the watch on that day. The Home has apologised for what happened and the distress this caused Ms D. I consider this to be an appropriate way to resolve the complaint about the watch.

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Agreed actions

Agreed actions for the Home

96. The Home will write to Ms D within one month of the date of this final decision to acknowledge each of the faults we have identified and to offer a meaningful apology for the problems they have caused.
97. To stop similar flaws relating to falls, care plan reviews, faulty equipment and record-keeping causing problems for other residents in the future, the Home will within two months of the date of this final decision provide staff with:
• clear guidelines on how to perform neurological observations, how frequently to perform them and how to record them, after a resident falls;
• a 1:1 observation policy;
• guidance on carrying out reviews of care plans at regular intervals and when there are relevant changes in circumstances;
• a clear procedure for checking and recording that safety equipment is in working order, and for what to do if equipment is faulty; and
• information about when to refer residents for a multidisciplinary assessment following a fall.
98. To stop similar faults with the DoLS process causing problems for other residents, the Home will within two months of the date of this final decision ensure relevant staff are fully aware of the current law and guidance for care homes on deprivation of liberty.
99. To stop similar faults relating to loss of possessions causing problems for other residents, the Home will, within two months of the date of this final decision, review its contract and consider adding information about:
• the property log;
• residents and relatives needing to inform staff about possessions they bring in after the property log is completed; and
• how it will deal with recording possession and loss of dentures, other prostheses, glasses or personal equipment necessary for a person’s health and safety.
100. Within two months of the date of this final decision, the Home will send:
• copies of its action plan to address our recommendations to Ms D, the CQC and the NHS Clinical Commissioning Group that commissioned Mr F’s place at the Home;
• evidence to the Ombudsmen that it has completed the recommendations.

Agreed actions for the Council

101. The Ombudsmen consider the Council accountable for the care Mr F received at the Home while his place there was funded by the Council. The Council will write to Ms D within one month of the date of this final decision to acknowledge each of the faults we have identified and to offer a meaningful apology for the problems they have caused.
102. To stop similar faults with the DoLS process causing problems for others in its area, the Council will within two months of the date of this final decision ensure relevant staff are fully aware of the current law and guidance for councils on deprivation of liberty.
103. Within two months of the date of my final decision, the Council will send evidence to the Ombudsmen that it has completed the recommendations.

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Final decision

104. The Ombudsmen uphold parts of Ms D’s complaints relating to falls, communication, capacity assessment, end of life care and loss of possessions. We do not uphold the rest of Ms D’s complaint. The Council and Home have accepted our recommendations, so we have completed our investigation.

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Parts of the complaint that I did not investigate

105. I have not investigated Ms D’s complaints about the Council’s handling of Mr F’s financial assessments. This is because an investigation would be unlikely to achieve more than the Council’s complaint response, in which the Council:
• apologised for not realising Mr F had died by the time it wrote to Ms D;
• confirmed it had reassessed Mr F’s client contribution taking into account Attendance Allowance; and
• wrote off the charges for a chargeable period of reablement.

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Investigator's decision on behalf of the Ombudsman