Mr K had a stroke in spring 2009. After his discharge from hospital, he received NHS-funded continuing health care and was discharged to the nursing home. In early summer 2012, his partner Ms L complained about the removal of possessions from Mr K's room and suggested that the change in layout of the room was not in his best interest. Ms L was subsequently told to stop visiting. After she complained about this, Ms L was allowed limited visits but restrictions were imposed and her contact with Mr K was supervised by members of staff.
What happened
A safeguarding referral was made in summer 2012 because Ms L was concerned that her exclusion was affecting Mr K's care. She was also concerned that her exclusion, the removal of certain items and the change of layout of Mr K's room were having a detrimental effect on his quality of life.
The safeguarding investigation concluded that the nursing home had provided no evidence that the actions taken were in Mr K's best interest and advised that they should be cancelled with immediate effect. It was also later concluded that the restrictions of contact imposed on Ms L, the change in the room layout, and the removal of possessions were unlawful within the framework of the Mental Capacity Act 2005 and should be lifted with immediate effect. Ms L said that despite these findings, it took the nursing home several months to comply with the safeguarding advice.
Ms L said that the restrictions imposed meant she was escorted at all times, which did not allow her and Mr K any privacy. She said that Mr K's health deteriorated as a result of the imposed sanctions. She was particularly concerned about Mr K's weight loss in the weeks and months prior to his death. Ms L was previously allowed to feed Mr K but this involvement was denied to her while these restrictions were in place.
Ms L was concerned that the nursing home had not apologised for its failings and displayed no learning or understanding of the suffering she and Mr K endured. She also said that there was no cascading of training and no evidence of better compliance with external authorities right up to mid-2013, when Mr K died.
What we found
Neither the Primary Care Trust (PCT) nor the Clinical Commissioning Group (CCG) considered fully Ms L's complaint about the nursing home.
Mr K received poor nutritional care in the six months prior to early 2013. However, there was no evidence that his weight loss compromised his overall health prior to his death.
It took the nursing home several months to comply fully with the findings and recommendations of the safeguarding investigation. We considered this poor service. The nursing home noted in internal documentation that it handled this situation poorly. However, it did not communicate this to Ms L or formally apologise to her. Nor did it apologise for the time it took to comply with the safeguarding recommendations.
We upheld the complaint.
Putting it right
We recommended the CCG should apologise to Ms L for the way the PCT and the CCG handled her complaint. We also recommended that the CCG should confirm what actions it planned to take to prevent similar instances of poor complaint handling in the future.
We recommended that the nursing home should apologise to Ms L for: its failure to initially recognise and manage Mr K's low weight in the six months prior to early 2013; the way it excluded Ms L from the home between summer 2012 until early 2013; the poor nutritional care given to Mr K during this period; and for the detrimental impact Ms L's exclusion had on her and Mr K's relationship and their quality of life; the way it deprived Mr K and Ms L of each other's company and his possessions; the way the nursing home changed the layout of Mr K's room; the time it took to put things back to the way they were and for the negative affect this had on his quality of life.
We also recommended that the nursing home should confirm what actions it plans to take to prevent similar instances of poor complaint handling in the future.
Malling Health
Bath and North East Somerset CCG
North Somerset
Did not involve complainant adequately in the process
Did not put recommendations into practice
Apology
Recommendation to learn lessons or draw up an action plan