A North London care home ‘failed its duty’ to provide the right support for a woman with dementia, an investigation by the Local Government and Social Care Ombudsman (LGO) has found. The council has been ordered to pay £550 in compensation after the woman suffered ‘a period of gum pain’ that required dental intervention as her lower denture hadn’t been removed or cleaned ‘in several months’ and staff ‘inappropriately used a knife’ to unlock her door when it was locked from the inside.
The investigation concluded that the care home, which is under the jurisdiction of Harrow Council, was at fault for causing ‘frustration and uncertainty’ and ‘avoidable discomfort’ to the woman – referred to in the report as Mrs Y. The LGO found Mrs Y wasn’t given appropriate oral care in line with her needs and using a knife to open her locked door raised safeguarding concerns.
Mrs Y, who has dementia and other health conditions, moved into the care home in December 2022 following a stay in hospital, with her daughter, referred to as Miss X, having power of attorney over her. The home provided her with a care plan, which stated that her dentures should be cleaned daily, however, it only made reference to an upper denture and not the lower one.
In July 2023, Miss X took her mother to the dentist after she was complaining of sore gums. The dentist subsequently wrote a letter to the care provider which described Mrs Y’s gum health as ‘poor’ and highlighted that they had struggled to remove her lower denture. The dentist noted that it ‘looked like it had not been removed for several months’, according to the LGO report.
The care plan also made no reference to Mrs Y being lactose intolerant, despite records showing that this was highlighted in her diet form, which was provided to the kitchen in December 2022. Miss X claimed that she saw her mother being given inappropriate foods but the LGO report states that this ‘would be very difficult to prove’, however acknowledged that the inaccuracy of the care plan caused uncertainty over whether Mrs Y’s dietary needs were being met.
Knife left outside her room regularly
In October 2023, Miss X saw a knife placed on the memory box outside her mother’s room and raised her concerns with the care home. She found that staff were using it to open Mrs Y’s door when she had locked it from the inside. Miss X was concerned that the knife could cause injury to Mrs Y or other care home residents but the care provider ‘did not see the knife could cause harm’. Miss X removed the knife but found it back in the same place the next time she visited, according to the report.
In a letter sent to Miss X from the care home manager, they apologised that a knife had been used to unlock Mrs Y’s door and claimed the message to not do this hadn’t been passed along to all staff as they had been off work. They said staff would now use a coin to unlock the door.
Staff had also advised Miss X of an incident where Mrs Y had used a tissue to clean up after another resident had ‘opened their bowels’ in her presence. A subsequent investigation by Harrow Council found that, although Mrs Y was not harmed, the care home’s actions ‘did not meet expected standards’.
Miss X complained to the care home about the incidents, as well as raising them with the Care Quality Commission (CQC). It raised a safeguarding concern with the council, which carried out a safeguarding investigation. The council ended the safeguarding in January 2024 after noting that the care home ‘was rectifying the mistakes’ and Miss X agreed there had been some improvement in her mother’s care – although it also noted she was ‘still not confident’ the care home could provide sufficient support.
Relationship had broken down
A meeting between the care home and social worker in January of this year concluded that the relationship with Miss X ‘had broken down’, that she no longer trusted the care provider and this couldn’t be fixed – a claim disputed by Miss X.
In late February, the care home ultimately gave Mrs Y notice to leave and she moved out in April. The LGO concluded that the evidence demonstrated the relationship between both parties had deteriorated and there was no fault in how the care home ended the contract. However, it did find fault with how some of the care was provided and ordered the local authority to pay £250 in compensation to Miss X and a further £300 to Mrs Y.
A spokesperson for Harrow Council said: “The London Borough of Harrow takes its duty to support those in need very seriously, we apologise for falling short of the level of care this resident should expect to receive. We accept the findings of the ombudsman’s report and will fully comply with the recommendations.
“We have assured the ombudsman that action has been taken including training and coaching for staff involved. The council has issued an apology to those parties involved and compensation has been accepted.”
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