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Wokingham council criticised after woman left severely malnourished during stay in care home

The Local Government Ombudsman has issued a report criticising Wokingham Borough Council after a vulnerable patient lost a third of her body weight while living in the care home it contracted to look after her.

The woman, who has aphasia (problems with understanding and speaking due to damage to part of the brain, usually caused by a stroke), arthritis and osteoporosis, entered the council-funded care home in 2010. At the time her weight was around 61kg.

When she entered the home, her care plan included instructions that she needed supervision with her mobility and transfers (changing position), help with personal care, help to take medication, to have adequate food and drink and encouragement to interact as she was in a low mood.

By the time she left that home in December 2013, her weight had plummeted to just 41kg. 

The woman’s family complained to Wokingham Borough Council about the care she received while in the home, also that she was understimulated and not supported when walking and fell, breaking her hip. The council responded to the complaint, accepting it had not supported the placement for the whole time the woman was there. It said it did not review her care as it should because of an administrative error. The council also accepted it had not advised the daughter that she could contact officers if she had concerns.

The council said the woman’s weight was of concern, that there was no activities co-ordinator in place and that the Care Quality Commission’s inspection concluded record keeping was poor. The council apologised to the family and offered them £500.

The family was not happy with the council’s response and complained to Ombudsman, who found fault with the council.

The LGO’s investigation was critical of the lack of personalised activities organised at the home. It also heavily criticised the care provided for the woman who left the home malnourished, and with a Body Mass Index of just 15 (government guidance says a healthy BMI is 18 to 25), and the lack of timely action taken to address her weight loss.

The LGO also criticised the care home’s record keeping, and that staff did not seek timely specialist support for her low weight. The investigation also found failings in the way the home planned and carried out risk assessments around falls and mobility for the woman.

Dr Jane Martin, Local Government Ombudsman said:

“This case highlights the need to remind councils that when contracting out services to third parties, they cannot contract out the accountability for those services. Sadly, this is an example where a vulnerable woman and her family have suffered because their council has neglected its duty to them.

“In this case the woman was bored, lost a considerable amount of weight and her wellbeing was not promoted. Fortunately, since moving to a different care home she has regained weight and is now within a healthy range.

“I now urge Wokingham council to consider seriously my recommendations and take on board the changes it needs to make to ensure other people do not suffer in this way.”

To remedy the situation, Wokingham council has been asked to pay the mother £3,500 and her daughter £500. The council has also said it has carried out quality visits to the care home in light of the family’s complaint. To minimise recurrence the Ombudsman has recommended the council includes specific spot checks around nutrition, falls and care plans for activities.

Article date: 05 January 2017