Countrywide Care Home at fault for causing injury, failing to protect dignity and for failing to meet personal care needs

Decision date: 25/10/19

What happened

Mrs M had resided in this care home since July 2015 and by September 2017, she was confined to her bed and needed support in all aspects of her care needs.

Mrs X was concerned with the level of care that Mrs M was receiving at the care home. She met with the manager in November to discuss several issues, including Mrs M lying in a wet bed for extended periods of time and for unexplained bruises and a small tear on her arms caused by a carer’s ring.

The manager wrote to Mrs X to address her concerns and said that the care home would review Mrs M’s care plan. The care home investigated the incident with the carer’s ring and reported it to the Council’s safeguarding team and to the Care Quality Commission. The Council wrote to Mrs X to say that the case had been closed after the care provider had taken the appropriate action.

The care home had recorded Mrs M as being aggressive to staff when they were administering care. The difficulties were discussed with Mrs X but there was some confusion with what had been decided. Mrs X believed that the care home had agreed not to shower Mrs M any more as it distressed her. However, the care home records say that it had only agreed that Mrs M would not be showered by staff members she was not comfortable with. Mrs X considered moving Mrs M to a new care home at this time but decided not to in case it was too disruptive for her.

Mrs X found a new bruise on Mrs M’s hands in February 2018 and found a skin tear on the same hand the next day. The care home manager reported this to the Council’s safeguarding team who noted Mrs M’s extremely frail skin in the subsequent investigation. The Council closed the case after deciding that again the care home had taken the appropriate action.

Mrs X raised further concerns with the care home manager in March. She said that Mrs M’s bathroom was dirty and that her dentures were sitting in dirty water. The care home said that they had not been brushing Mrs M’s teeth due to her aggressiveness, but did also acknowledge the difficulties it was having in caring for her. The G.P prescribed Mrs M sedatives to ensure that personal care was able to be given.

In April, Mrs X reported Mrs M as sitting in a very soiled pad. A carer apologised and changed it.

Mrs M became at risk of choking in July due to her sucking on toys and bedding. This was recorded in her care plan.

In August, a relative told Mrs X that she had seen Mrs M being fed with no clothing on her bottom half, due to the care home having ran out of pads. This was reported to the Council’s safeguarding team in September who investigated the incident. The care home accepted the claims but said that there were valid reasons that Mrs M had not been clothed, which the Council accepted.

In September, Mrs X once again raised concerns about the state of Mrs M’s bathroom and said that the care home failed to respond to this complaint. Mrs X met with the care home manager in early October to discuss her concerns.

Four days later, the care home wrote to Mrs X giving Mrs M 28 days’ notice. Mrs X got in touch with the Council’s safeguarding team and sent photographic evidence of the concerns that she had about the level of care at the home. These pictures included bruising, skin tears and poor hygiene.

A meeting was held in October between a Council officer, the care home manager and Mrs X. The care home accepted responsibility for the low standard of care and agreed a plan of action to address Mrs X’s concerns. After the meeting, Mrs X claimed that the care home manager had told her she would revoke the eviction notice. However, the care home has no record of this.

A Council officer visited Mrs M around this time and recorded that her room was ‘not free from dirt’.

A new manager was appointed by the care home in December. Mrs X made a formal complaint and raised several concerns about:

  • Mrs M lying in dried faeces that was stuck to her bottom and the sheets;
  • Mrs M lying on a soiled sheet and the mattress not wiped;
  • Carers using an unsafe method for moving Mrs M in bed;
  • Mrs M being given a gift with a ribbon that was a choking risk that care staff did not remove;
  • Mrs M being showered and left with wet hair when she was full of cold. The same day the GP diagnosed a chest infection and prescribed antibiotics.
  • The new manager deciding Mrs M should be checked every two hours, when previously Mrs M was checked every 30 minutes because of the high choking risk.

The care home responded to the formal complaint in January 2019. It said:

  • It had provided care according to Mrs M’s plan
  • Mrs M was known to remove her continence products and staff monitored her through the day to ensure she was not left in soiled bedding;
  • All staff had appropriate training for moving and handling – the carers involved in the incident complained about were agency staff and agency staff were no longer used.
  • 30 minute checks were agreed by a previous manager in November 2017 for a limited period. This was reviewed and discontinued in April 2018.

On the same day as responding to the complaint, the care home wrote to Mrs X to say that the eviction notice still stood despite the 28 day period having already elapsed. It asked Mrs X to provide details of a new placement within 4 weeks.

Mrs X complained to the Ombudsman about the level of care provided, that the care home ignored her complaints and that it issued an eviction notice because of the complaints the family had made.

What was found

The Care home were found at fault initially for failing to make detailed recordings of the care given, or of what action was taken when care was refused. The Council advised the care home on how to improve in December 2018 and the care home had provided evidence of it implementing this advice.

The injury to Mrs M caused by the carer’s ring amounted to injustice as it was fault and caused distress to Mrs M and Mrs X. However, the carer did apologise and proper action was taken by the care home.

The Ombudsman could not find sufficient evidence to find the care home at fault for the unexplained bruise in February or for the complaint in March about the dirty bathroom and dentures.

There was fault found in the care home feeding Mrs M whilst she was not fully clothed, despite its claims that she did not like wearing clothes on her lower body. The care home did not sufficiently protect Mrs M’s dignity and this caused distress to her and her family.

Despite Mrs M’s needs being generally met, there were times when they were not, particularly regarding personal care. The care home was at fault for its failings in relation to cleanliness in Mrs M’s room in October, and this caused distress to Mrs M and her family.

With regards to the increase in time between checks, the care home was assessed as properly considering the risk of choking as there were no records of any incidents in the time period under investigation.

The LGO said that the care home’s position was that it had implemented the actions recommended by the council’s safeguarding social worker and had tried to mediate with the family. However, the family continued to raise concerns with the care home and did so in an aggressive manner, according to the home.

The care home considered its relationship with the family had broken down.

There was nothing on the contract with the care home that restricted its powers to terminate placements on 4 weeks’ notice.

The original notice was effectively suspended whilst the complaints were being investigated by the Council. When the care home manager asked Mrs X to find an alternative provider for Mrs M it allowed her 4 weeks in which to do so.

This was in line with its contract and therefore the care home was not at fault for terminating the placement.

The care provider agreed that it would, within one month of the final decision, apologise to Mrs X for its failure to meet Mrs M’s personal care needs and pay her £250 to acknowledge the distress caused to her. It would also pay Mrs M £500.

Points for the public, service users, families and councils

Although nothing is said, specifically about the Human Rights Act and what it adds to any council’s obligations to a council client, or its inputs through safeguarding, the most it could do would be require further efforts to manage a complainant’s expectations. The mood in the country these days is more often ‘Enough is enough’ and that is enough to make many relatives very unhappy. We think it would be much better if providers were legally literate enough to get decent care packages for individuals in the first place, because they would then not be so desperate and defensive with people’s relatives.

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The full Local Government Ombudsman report on the actions of Countrywide Care Home can be found here: