Summary: Ms X complained about the standard of care given by the Care Provider, to her mother, Mrs Y, who entered one of its care homes as a temporary resident in June 2022. We upheld the complaint finding a series of failings by the Care Provider. These included a failure to provide safe care to Mrs Y, to meet her hydration needs and keep satisfactory records. These failings caused Mrs Y avoidable distress. They also caused uncertainty to Ms X in not knowing if better care could have prevented Mrs Y’s subsequent admission to hospital where she later died. The Care Provider has agreed a series of recommendations for actions it will take to remedy this injustice and improve its service, set out at the end of this statement.

The complaint

1. I have called the complainant, Ms X. She complains about the standard of care provided by Barchester Healthcare Homes Ltd (the ‘Care Provider’) to her mother, ‘Mrs Y’, who entered Marriott House and Lodge Care Home (the ‘Care Home’) in June 2022.
2. Specifically, Ms X complains the Care Provider failed:

• to identify that Mrs Y was suffering from sepsis. She entered hospital with sepsis on 5 July 2022;
• to meet Mrs Y’s hydration needs;
• to provide Mrs Y adequate care when she contracted a COVID-19 infection at the Care Home;
• to prevent Mrs Y’s isolation and loneliness. For around 10 days, the Care Home required Mrs Y to self-isolate and it prevented any visitors to her. Ms X understands this was contrary to Government guidance in force at the time;
• to provide a satisfactory explanation for an injury to Mrs Y’s leg, first noted around the time she had a fall on 27 June 2022;
• to follow its procedure for fitting bed rails on Mrs Y’s bed;
• to ensure satisfactory continence care for Mrs Y;
• to adequately support Mrs Y with her medication needs;
• to communicate adequately with her while Mrs Y was in its care. Ms X says it did not alert her to a decline in Mrs Y’s health. Further, in answering her complaint, Ms X says the Care Provider offered a confusing account of its contacts with GP services.

3. Following admission to hospital on 5 July 2022, Mrs Y did not recover. She died around three weeks later with sepsis, the primary cause. Mrs Y’s death certificate lists COVID-19 as a secondary cause (with other causes). Ms X believes better care from the Care Provider could have prevented her mother becoming so ill and potentially prevented her death. In any event Ms X says Mrs Y suffered unnecessary distress because of poor care received and this has caused Ms X distress in turn.

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The Ombudsman’s role and powers

4. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
5. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
6. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

7. Before issuing this decision statement I considered:

• Ms X’s written complaint to the Ombudsman and supporting information she provided. This included correspondence she exchanged with the Care Provider making her complaint and its replies. Included within that was a detailed chronology document compiled from Ms X which relied on contemporaneous text messages she sent to her sister, updating on their mother’s well-being. I also gathered information from Ms X in a telephone call and she sent me documents relevant to Mrs Y’s admission to hospital on 5 July. These included notes of the ambulance service, hospital and Mrs Y’s death certificate.
• Information provided to me by the Care Provider in response to written enquiries. This included care planning documents the Care Home completed for Mrs Y on admission. It also sent me running daily care notes and assorted other records relevant to the complaint such as records of any falls experienced by Mrs Y or medical advice sought. The Care Provider also made further comments on the case in reply to my enquiries.
• Information provided by the GP surgery Mrs Y registered with, while she resided at the Care Home. In particular, to clarify contacts from the Care Provider and prescriptions given between 2 and 5 July 2022.
• Relevant national guidance produced by the care home regulator, the Care Quality Commission, which I discuss below.
• Relevant guidance published by this office including guidance we issue to Care Providers on record keeping and setting out our approach to remedying complaints.

8. I also gave Ms X and the Care Provider a chance to comment on a draft version of this decision statement. I took account of any comments they made before finalising the decision statement.
9. Under an information sharing agreement, we will share this final decision with the care home regulator, the Care Quality Commission (CQC) in advance of publication on our website.

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What I found

Legal and Administrative Background

Relevant CQC guidance

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards. We take account of the standards and accompanying guidance when deciding if a Care Provider has acted with fault.
11. I consider the following fundamental standards relevant to this complaint:

• Regulation 10, which covers ‘dignity and respect’. This includes ensuring staff treat all those using care services in a caring and compassionate way.
• Regulation 12, which covers ‘safe care and treatment’. Providers must prevent and control the spread of infection. They must undertake appropriate risk assessments for those in their care. Staff must also respond appropriately if there is a medical emergency. And there must be suitable systems in place for administering medications accurately as prescribed.
• Regulation 14, ‘meeting nutritional and hydration needs’. This says providers must meet the nutrition and hydration needs of service users. This includes recording those needs in care plans and reviewing them on an ongoing basis.
• Regulation 17, which covers ‘good governance’. This requires providers to keep accurate, complete and detailed records about each person using their service.
• Regulation 20, which requires care providers to have a ‘duty of candour’ to act in open and transparent way when delivering care. It places an expectation on care providers to say sorry when poor care has caused harm.

Relevant National guidance on visiting care homes

12. In March 2022 the Government published guidance effective from 4 April 2022, in the ‘COVID-19 supplement to the infection prevention and control resource for adult social care’. This said all care home residents who tested positive for COVID-19 should isolate for 10 days “within their own room”. The guidance said care providers should closely monitor symptoms and consider if the resident might be eligible for treatments such as antiviral medications.
13. The guidance said: “Isolation does not preclude receiving one visitor [..]”. It also said: “contact with relatives and friends is fundamental to care home residents’ health and wellbeing and visiting should be encouraged. There should not normally be any restrictions to visits into or out of the care home. The right to private and family life is a human right protected in law (Article 8 of the European Convention on Human Rights). Where visiting is modified during an outbreak of COVID-19 or where a care home resident has confirmed COVID-19, every resident should be enabled to continue to receive one visitor inside the care home […]”.
14. The Government updated this guidance between April and June 2022, but the passage above remained in force during events covered by this complaint.

Relevant Ombudsman guidance

15. In February 2023 we published a practice note on ‘good record keeping’ in social care. This highlighted guidance produced by CQC in support of Regulation 17 as well as guidance from NICE (National Institute for Health and Care Excellence) on medication records. Drawing on our experience of investigations, we stressed the need for providers to keep records that are accurate, honest and comprehensive; and updated with new information in a timely way.
16. In December 2022 we published guidance setting out our approach to complaints that raise concerns about human rights. Our remit does not extend to deciding on whether an organisation has breached the Human Rights Act – only the courts can do this. But we can make decide whether an organisation has shown due regard to an individual’s human rights in their treatment of them, as part of our consideration of a complaint.
17. Copies of this guidance can be found here: Focus Reports and Good Practice Guides - Local Government and Social Care Ombudsman

Key facts

18. Mrs Y was a single woman in her nineties. She lived in her own home, near to the Care Home, supported by her daughter Ms X. In the months before June 2022 Mrs Y experienced some ill health, resulting in hospital stays. Following a short hospital admission in June 2022, Mrs Y decided to move into the Care Home for a temporary stay, funding her own care. Mrs Y had some familiarity with the Care Home having visited it previously. She wanted to stay for two weeks, while Ms X arranged extra domiciliary care for her and an adjustable bed for her return home.
19. Mrs Y entered the Care Home on 17 June 2022. The Care Provider completed various care planning documents with Mrs Y on admission. These recorded:

• that Mrs Y had hyponatraemia, or low blood sodium levels. Her hospital discharge advised she should not have more than 1.5litres of water or other drinks a day because of this condition. The Care Provider recorded this in its notes. But Mrs Y’s care plan, recording her nutrition and hydration needs did not note this condition or this advice;
• Mrs Y needed support with personal care such as washing, dressing and so on because of physical health needs;
• that Mrs Y exercised caution when mobilising following some previous falls. She used a walking frame;
• that Mrs Y had some continence needs but was largely independent in this area, using a commode at night;
• the Care Provider would support Mrs Y with medications she took, saying it would administer these.

20. On 18 June 2022 the Care Provider undertook a risk assessment to see if Mrs Y was at risk of pressure sores. As part of this assessment, it completed a body map which noted Mrs Y had bruising on both legs. Notes accompanying this assessment referred to these as “old bruises”.
21. The Care Provider did not complete any assessment of whether Mrs Y needed bed rails fitting on her bed. The care plan recorded that because of Mrs Y’s concerns about falls, it would check on her well-being hourly. Those checks identify that from the time Mrs Y moved into the care home, bed rails were in place. However, Ms X, who says she visited Mrs Y every day up to 21 June, said the bed rails were only present from 21 June.
22. On 22 June 2022, Ms X tested positive for COVID-19. She called the Care Home, who tested Mrs Y and she also tested positive. The Care Home documented this in two places – the daily running care notes and in a separate note. Both imply she was asymptomatic at the time. The note recorded advice to staff that they should alert a nurse or senior officer, if Mrs Y showed “any signs” of the infection.
23. The Care Provider required Mrs Y to self-isolate in her room from this day onward. It arranged for its activity co-ordinator to visit Mrs Y for half an hour in her room each day.
24. Ms X understood that while she had COVID-19 she could not visit Mrs Y. But her sister could visit Mrs Y. However, the Care Home told Ms X that Mrs Y could not have any visitors. Ms X would phone the Care Home regularly and write Mrs Y postcards. She understood the Care Home read these to Mrs Y. Ms X has told us that Mrs Y was hard of hearing (recorded also in her care plan) and so a telephone call may have distressed her. However, she thinks Mrs Y would have enjoyed contact via a video link such as Facetime. In her telephone calls to the Care Home, Ms X says she was regularly reassured that her mother was ‘fine’.
25. The Care Provider has provided only one note of where Ms X spoke to a member of its staff between 22 June and 1 July, dated 23 June. The note indicates the staff member checked on Mrs Y, before reporting to Ms X that Mrs Y appeared fine. There is nothing in the note suggesting Mrs Y had any symptoms of COVID-19 at that time.
26. From 24 June 2022 onward, the care notes record that staff noted Mrs Y was sleepy. For the first time in the daily care log there is also reference to Mrs Y needing help because of incontinence.
27. On 26 June the Care Provider recorded Mrs Y spending her day in an armchair but said there was “no concern”.
28. On 27 or 28 June 2022 Mrs Y’s legs gave way beneath her when she was supported by staff. There are multiple records of this incident, with incident forms dating it as 27 June. However, the daily care log refers to an incident on 28 June. The accounts all refer to staff helping to ‘guide’ Mrs Y to the floor, and checks finding she had no injuries. There are also records the Care Provider checked over the subsequent 48 hours that Mrs Y had not suffered any injuries.
29. The Care Provider completed a body map on 27 June. This noted a skin tear to Mrs Y’s left leg. A photograph accompanying this, dated 27 June, shows bruising around the skin tear. Notes accompanying the assessment of the wound list ‘factors which may delay healing’ and the Care Provider wrote “frailty, nutritional risk, not eating/drinking much”.
30. On 28 June 2022 the Care Provider recorded Mrs Y complaining of loneliness. Ms X says she rang the Care Home that day to check on Mrs Y’s health. It told her about what it described as a ‘stumble’ incident. Ms X says care home staff told her that Mrs Y was ‘doing okay’ and that she was eating and drinking.
31. On 29 June 2022 the daily log records that Mrs Y’s “cough was still not good”. The following day the Care Provider recorded that Mrs Y’s cough was worse when in bed and it helped her to sit in her chair. It again recorded she was lonely and missing her daughters. On 1 July 2022 the Care Provider recorded Mrs Y staying in bed “with her consent”. A separate note said the Care Provider “monitored with her temperature and made comfortable”.
32. On 1 July, Ms X began testing negative for COVID-19. She said the Care Home again declined her request to visit Mrs Y, saying Mrs Y needed to test negative for COVID-19 first.
33. On 2 July the Care Provider recorded Mrs Y “very poorly this morning”. It undertook another COVID-19 test, which was again positive. It also tested for a urinary tract infection (UTI), which was also positive. The Care Provider recorded calling a GP who prescribed antibiotics, which staff could collect that day. The Care Home spoke to Ms X about Mrs Y’s deterioration. Ms X again requested a visit, which this time it agreed.
34. In Ms X’s own words when she visited Mrs Y on 2 July:

• “I was shocked and very distressed by [Mrs Y’s] deterioration. During my visit, she was either extremely drowsy or asleep, or when awake, she seemed very confused. She had a cough. She was weak, barely able to speak, and not making much sense when she did speak. She at times became distressed by the wound on her leg (she was given painkillers while I was there), and also at times became agitated trying to push off all her bed clothes. Her mouth was very dry, and her lips and teeth were blackened. Her fingernails were filthy. She was not able to use a toilet or commode. The bedrails on her bed were up, and she had no call button (she wouldn’t have been alert enough to use one).”

35. The Care Provider’s medical record records giving Mrs Y a double-dose of the antibiotic on the afternoon of 2 July. Beneath this it then records giving Mrs Y the antibiotic at 5.00pm, also on 2 July and then further doses, three times a day on 3 and 4 July. It gave a final dose to Mrs Y on the morning of 5 July.
36. On 2 July the Care Provider also kept a record of Mrs Y’s fluid intake, which was less than 400ml for the whole day. There is a second fluid intake record which the Care Provider says dates from 3 July, although the date recorded is unclear. This includes entries throughout the afternoon, including three entries made after 3.00pm. There are no fluid intake charts for 4 or 5 July 2022.
37. Between 27 June and 3 July the Care Provider checked Mrs Y’s leg wound. This second check is undated but it records the Care Provider finding an odour from the wound. Its check said Mrs Y did not have an infection. It recorded dressing the wound with a dressing containing an antimicrobial agent.
38. On 3 July the Care Provider recorded changing a dressing on Mrs Y’s leg wound and checking its condition. It no longer recorded an odour from the wound.
39. On 3 July and 4 July, the daily logs continued to record Mrs Y as sleepy or lethargic. On 4 July Mrs Y returned a negative COVID-19 test. Ms X visited both days and said while Mrs Y appeared slightly better on 3 July, she had deteriorated the following day. She found her thirsty and Mrs Y drank when Ms X encouraged her to.
40. On 5 July the Care Provider recorded Mrs Y had become agitated. The running care notes say her chest was “bubbly” and she had a dark tongue. A note timed at 11.00am refers to Mrs Y having “central cyanosis”. This is a medical term that refers to a bluish discoloration on the skin or tongue, caused by inadequate oxygenation.
41. The Care Provider recorded calling the GP surgery which was closed until midday and then calling NHS 111 which arranged someone call back in the afternoon. Meanwhile, the Care Home spoke to Ms X who asked it to call an ambulance, which the Care Home went on to do. It recorded doing this at 2.00pm and the service arriving around 2.30pm when Mrs Y went to hospital. The ambulance service notes begin from 3.00pm. They show the ambulance crew considered Mrs Y had sepsis, later confirmed following her admission to hospital.
42. A further record kept by the Care Provider shows a prescription for Mrs Y’s antibiotic beginning on 5 July. The GP surgery notes record speaking twice to the Care Home, initially at 11:40am. They record being told Mrs Y still had a UTI and that Mrs Y had received a three-day course of antibiotics. The GP had no record of that prescription. It agreed to prescribe a week of medication.
43. Later, at 2.40pm the GP surgery recorded speaking to someone else at the Care Home (the callback arranged via NHS 111) “who was unaware someone has already spoken to the duty doctor at the surgery a few hours ago”. The Care Home told the GP it had, by that time, called an ambulance.
44. Ms X arrived at the Care Home on 5 July, before Mrs Y’s admission to hospital. She was distressed by Mrs Y’s presentation. She says that she needed continence care on her arrival, which staff had not attended to. She also found a pill on Ms X’s bed.
45. The hospital notes provided by Ms X state that as well as having sepsis, Mrs Y had dehydration on admission.

Ms X’s complaint

46. In September 2022 Ms X made a complaint to the Care Provider, which it answered at the end of November 2022. It apologised for not answering the complaint sooner. It had initially promised a reply at the start of the month. It then wrote to Ms X saying the response would be made towards the end of the month (in the event it was sent another week later).
47. In her complaint Ms X ran through her contacts with the Care Provider, while Mrs Y was at the Care Home. She asked for clarity about what steps the Care Home took to seek medical advice and if it considered if Mrs Y might have sepsis. Dissatisfied with its first reply, Ms X later escalated her complaint in January 2023 and the Care Provider gave its final response in April. I note the Care Provider publishes details of its two-stage complaint procedure. It says that at both Stage 1 and Stage 2 it aims to provide a reply within 20 working days. The Care Provider says it regrets it could not meet those timescales in this case. It says issues such as staff availability, recovering care records and other demands on the business can impact on these.
48. In its replies, the Care Provider said:

• that its staff cannot diagnose illness, but that it will contact medical professionals if concerned for the health of a resident. That in this case it had shared Mrs Y’s symptoms with the GP surgery, including that it had confirmed Mrs Y had a UTI. It said its staff could access awareness training on the signs and symptoms of sepsis and there are posters around its care home on this subject. In comments to us, the Care Provider has clarified it recommends this training to nurses it employs, but it is not compulsory;
• that throughout Mrs Y’s stay at the Care Home it encouraged her to eat and drink, but only ‘formally monitored’ this from 2 July. It considered that Mrs Y’s decline in presentation from 2 July was potentially due to various factors including her UTI and COVID-19. Had the GP encouraged Mrs Y’s admission to hospital that day it would have done so;
• that it could not say how Mrs Y’s skin tear occurred;
• that it recognised it should have allowed a visitor to Mrs Y after she tested positive for COVID-19 and / or facilitated a video call between Ms X and Mrs Y. It says the Care Home misunderstood guidance and company policy then in force. It apologised for this;
• that it recognised not assessing Mrs Y’s need for bed rails or discussing this with Ms X. It would remind staff of the proper procedure. It apologised for this.
• that Mrs Y had a gradual greater need for continence care as her condition worsened and understood its staff supported her with that;
• that it had no record of the pill found by Ms X on 5 July; that Mrs Y occasionally refused medication;
• it apologised for any confusion around information given to Ms X concerning the antibiotics prescribed to Mrs Y;
• it also apologised if its staff had not explained the full extent of Mrs Y’s deteriorating health to Ms X.

My findings

49. I have considered each part of Ms X’s complaint in turn. I set out my findings on fault below, before considering the consequences of any fault later in this statement.

The complaint the Care Provider failed to identify Ms X had sepsis

50. Sepsis is a life-threatening condition, caused by the body overreacting to an infection. The NHS advises calling 999 if someone has confusion, slurred speech, is not making sense or if they have ‘blue or grey’ lips or tongue, a rash or difficulty breathing. It advises calling 111 if someone feels very unwell or that there is something seriously wrong; if they have not urinated for twelve hours, is vomiting, have swelling around a cut or wound, or have a high temperature.
51. On balance, I do not think we could say that Mrs Y was showing clear signs of sepsis before 5 July. I consider there were three distinct phases to Mrs Y’s deterioration. First between 24 June and 1 July, the notes indicate a gradual worsening of Mrs Y’s condition (see further comments below). Then on 2 July they record her becoming more poorly which coincided with a positive UTI test. But on 5 July there was a step-change again in Mrs Y’s presentation, with her becoming even more markedly unwell. Notes referring to changes in her breathing, agitation and cyanosis all indicate just how poorly she had become.
52. I accept that care staff are not medical practitioners. I accept also that their knowledge and experience of caring for residents might lead them to think the symptoms Mrs Y had could have been because of her UTI. However, given these new symptoms I struggle to understand why the Care Provider was not seeking urgent first-hand examination by a medical professional from the morning of that day. And it is clear Mrs Y would not have received emergency care, which immediately diagnosed she had sepsis, had not Ms X asked for it. Reading Mrs Y’s symptoms alongside the advice on when to call 999 if you suspect sepsis, then it is not only with hindsight that I can say the Care Home should have called an ambulance earlier that day.
53. Consequently, I do not consider the Care Provider reacted with enough urgency on 5 July, which suggests a failure to meet the fundamental standard for delivering safe care. That was a fault.
54. I recognise the Care Provider currently makes some efforts to encourage its clinical staff to develop their professional knowledge around sepsis. It also makes some information about the condition available to all staff. But this case should act as a catalyst for it to review the efforts it makes in this area, something I am pleased to see that it accepts. The steps it will take here are set out in the section headed ‘agreed action’ below.

The complaint the Care Provider failed to meet Mrs Y’s hydration needs

55. I am concerned about how the Care Provider managed Mrs Y’s needs in this area, from the time she moved into the Care Home. It knew she had low sodium levels. But it did not cross-reference this information in her care plan.
56. Mrs Y was put at risk of harm therefore, from the time she moved into the Care Home. However, I note that in the event there is no suggestion the Care Provider ever oversaw her taking too many fluids.
57. Instead, the concern is the Care Provider did not ensure Mrs Y had enough hydration. There is evidence that staff knew Mrs Y was not drinking enough, in the paperwork which accompanied the assessment of her leg wound on 27 June. The Care Provider noted there she was “eating and drinking little”.
58. But there is no evidence the Care Provider was considering any risk posed by this. Clearly, by 2 July Mrs Y was not getting anywhere near the amount of hydration needed. The Care Provider’s fluid intake chart for that day and Ms X’s account of her visit provide compelling evidence for this.
59. The decision to keep fluid intake charts shows the Care Provider was eventually alert to this. But it did not then ensure the necessary monitoring took place. Because there is no evidence the Care Home recorded Ms X’s fluid intake beyond 3 July 2022. On balance, despite the date on that record being unclear, I am minded to accept it was made on 3 July. But the Care Provider acknowledges having no records for 4 or 5 July which was a fault. This suggests it breached the fundamental standard for good governance, requiring effective record keeping.
60. But given also what Ms X found on her visits between 2 and 5 July and Mrs Y’s presentation on admission to hospital, I consider the fault goes beyond this. It points to a significant failure by the Care Provider to meet another of the fundamental standards of care, that of ensuring it met Mrs Y’s hydration needs. That was also a fault.

The complaint about the Care Provider’s care for Mrs Y after she tested positive for Covid-19

61. Government guidance in force in June 2022, made clear that where a care home resident tested positive for COVID-19 the Care Provider should monitor their condition. I note an instruction to staff to do this followed Mrs Y’s initial positive test.
62. I am satisfied the evidence in this case points towards Mrs Y being asymptomatic on testing positive on 22 June. But from 24 June onward, until Mrs Y’s condition took a notable decline on 2 July, there is evidence she was getting progressively more poorly.
63. There is no single document which sets out Mrs Y’s changing condition, but a series of pointers in the care notes. There are consistent references to her tiredness and sleeping. There is the record of 27 June which noted Mrs Y was eating and drinking little. There are the first references to her needing continence care. There was one instance, or possibly two, where Mrs Y’s legs gave way from under her (see below) on 27 and 28 June. While on 29 June, a care worker said Mrs Y’s cough was “still not good”, implying she had developed a cough some time earlier. The Care Provider did not record when her cough began.
64. Yet despite all this evidence of deterioration in her health there is no indication the Care Provider sought to review how it should treat Mrs Y’s COVID-19, nor if it should seek medical advice and potential treatment. I note one reference to Mrs Y’s cough apparently responding positively to her sitting in a chair as opposed to lying ‘prone’. But there was no systemic review of her care to consider if care staff should ensure this happened every day.
65. Overall, the impression given is one of inattention and complacency once Mrs Y started to show symptoms of COVID-19. That might suggest a failure by the Care Provider to meet the fundamental standard to meet Mrs Y’s need for safe care and treatment. It also results in another finding of fault.

The complaint the Care Provider left Mrs Y isolated

66. I recognise the Care Provider has acknowledged a failure here, in that its Care Home did not recognise the change in Government guidance that took place in April 2022. This made clear that a positive COVID-19 test should not prevent a resident in a care home receiving a visit. While Ms X could not visit Mrs Y while she also had COVID-19, her sister could have done so.
67. I consider the Care Provider further at fault for its failure to offer Ms X and Mrs Y an alternative means to keep in touch while both isolated. The Care Provider knew of the close relationship between Ms X and Mrs Y. This was shown by Ms X’s commitment to visit Mrs Y daily when she could and her telephoning for updates after she could no longer do so. It also knew that Mrs Y missed such contact as its notes record this.
68. By June 2022 the pandemic was in its third year and care providers had much experience therefore of promoting contact for relatives kept apart by the virus or associated visiting restrictions. Seen in this context, the failure to offer Mrs Y a visit from her other daughter or a Facetime connection with Ms X (or similar alternative) therefore suggests more than just an oversight. It suggests a failure to consider Mrs Y’s human rights, something central to Government advice on visiting. This lack of attention to Mrs Y’s needs for connection to her family, was a further fault.

The complaint about Mrs Ys’ leg injury

69. I am satisfied Mrs Y entered the Care Home without a skin tear to her left leg, given the body map completed on 18 June. So, the injury happened some point before 27 June. Looking at the bruising on the photograph taken 27 June, I think it unlikely it happened that day but sometime before. I think it therefore unconnected with any stumble Mrs Y had where she was ‘guided’ to the floor.
70. It is another deficiency in the Care Provider’s notes that the ‘stumble’ incident could have happened on 27 or 28 June, or possibly there were two similar incidents in two days. But the description of neither would cause the injury Mrs Y presented. In which case I accept its cause was unknown. I note here that on entering the Care Home Mrs Y could mobilise independently and the Care Provider could not supervise her 24 hours a day. I could not find it at fault that Mrs Y experienced the skin tear assuming this resulted from an unwitnessed incident.
71. But its management of this matter again gives cause for concern. First, why did the Care Home not record the tear before 27 June given it is unlikely to have occurred that day. Records say that Care Home staff were giving Mrs Y personal care and she was mobilising less over time. So, why was this tear not noted or commented on before?
72. Second, I am concerned by the reference to Mrs Y’s wound smelling, which despite the statement she did not have an infection would be suggestive of that. The Care Provider’s record keeping is again poor as this record is undated, made sometime between 27 June and 3 July. I note the possible presence of infection indicated also by Ms X’s observations on 2 July, finding her mother distressed by the wound.
73. I am concerned that despite this, I can find no advice to staff on checking for further symptoms associated with possible infection or how this might affect Mrs Y. It is also unknown what consideration, if any, the Care Provider may have given to a wound infection contributing to Mrs Y’s overall deterioration in health, noticeable from late June and significantly worse from 2 July.
74. The poor record keeping and lack of attention to this matter suggest further failings by the Care Provider in meeting the key fundamental standard of care to keep residents safe. I again find fault therefore.

The complaint about the Care Provider fitting bed rails

75. The Care Provider has again acknowledged fault, as it did not follow proper procedure before fitting these. It has shared that procedure with me which makes clear the Care Provider’s policy to only fit these where necessary for the health and safety of the resident. It expects its staff to therefore risk assess before implementing such a measure. It expects the care plan to reflect the decision.
76. But in this case there was no risk assessment, and no mention in Mrs Y’s care plan of any requirement for these. Further, the record is also confusing about when the Care Home fitted the bed rails, as its notes suggest this was from Mrs Y’s admission. But Ms X only noted them on her fourth visit to the Care Home.
77. I cannot say the Care Provider was at fault for fitting the bed rails, as potentially there may have been reasons to do so. But it was at fault for failing to keep any record of its decision or the reasons for it. This again suggests a breach of the fundamental standard to keep accurate care records.

The complaint about the Care Provider’s continence care

78. The care records show when Mrs Y entered the care home she had a minimal need for help in this area of her personal care. The need increased as Mrs Y became more ill.
79. The care records show staff helped Mrs Y with continence care. There would come a point, where I would expect the Care Provider to have reviewed its care planning to include specific planning for this need. However, I would not necessarily expect to see this in circumstances where the need arises from short-term illness. So, I do not find fault in the Care Provider’s care planning for this need.
80. That said, I accept Ms X’s account of Mrs Y’s presentation on 5 July. I understand her distress in finding the Care Provider had not met Mrs Y’s needs in this area at that specific time. But I consider this evidence alone is not enough for me to find the Care Provider failed to meet Mrs Y’s needs in this area.

The complaint about management of Mrs Y’s medication

81. I have further concerns here. I accept the pill Ms X found among Mrs Y’s bedding may have been a one-off and not necessarily indicative of a wider problem. But I have found chaotic record keeping around the contact the Care Home had with GP services, after Mrs Y tested positive for a UTI.
82. I am satisfied on balance the Care Home did contact a GP on 2 July 2022 as it recorded this in some detail in the notes. Further it also recorded giving Mrs Y the antibiotic that day and for the next three days. I cannot account for why no equivalent record appears on the NHS record, but the fault for that could lie with the NHS.
83. But I find two different members of staff from the Care Home then contacted Mrs Y’s GP surgery on 5 July. But only one of those members of staff left a record of their contact. Meaning the other was unaware of the conversation that took place earlier in the morning where the surgery prescribed another week of antibiotics.
84. I commented above that I do not consider contacting the GP was the right course of action at this stage, given how ill Mrs Y evidently was on 5 July. But this further error again indicates a failure by the Care Provider to meet the fundamental standard for good governance. That was a fault.

The complaint about communications

85. I note with concern the lack of record keeping by the Care Home, about its communications with Mrs Y. I accept it is unrealistic to expect the Care Provider to keep a record of all communications with relatives, which on occasion may be brief or of limited significance to a resident’s care. But in circumstances where a resident is ill and a relative unable to visit, I would hope to see some record of how the Care Provider kept in touch with their next of kin.
86. In this case the Care Home records are brief. But they do confirm Ms X’s account that in the initial days after Mrs Y tested positive for COVID-19 it told her all was fine. I consider this corresponds with the care record. And that it was not until after 24 June 2022 records show a deterioration in Mrs Y’s condition.
87. As there is no record by the Care Home of any conversations it had with Ms X between 24 June and 1 July, there is nothing that contradicts her account of how totally unprepared she was for how Mrs Y presented by 2 July. I accept that on that day the notes indicate Mrs Y’s presentation had declined more noticeably. But as I explained above the notes before that date point towards a decline in Mrs Y’s health. The Care Provider should, in the spirit of the duty of candour, have told Ms X this as part of a commitment to deliver care in an open and transparent way.
88. The Care Provider’s handling of Ms X’s complaint was also poor. It acknowledges delay at both stages of its complaint procedure. I recognise the Care Provider did largely keep in touch with Ms X to inform her of that. Also, that there may have been particular resource pressures at the time, delaying those responses. The failure to adhere to the company’s own complaint procedure is however, still a service failing.
89. A bigger issue I consider is the lack of candour in the replies to Ms X’s complaint. I have set out above a series of flaws in its response to Mrs Y’s deteriorating health, its management of her hydration and most obviously in its record keeping. Some of this must have been apparent to the Care Provider when it replied to Ms X’s complaint. But the Care Provider did not share this key information with Ms X in its replies. That was a fault.

The impact of these faults

90. I consider the pattern of faults identified above point conclusively towards the Care Provider not providing Mrs Y with adequate care after she became ill. I am satisfied this will have caused avoidable distress for Mrs Y. In particular by not having her hydration needs met. The poor care Mrs Y received will also have caused distress for Ms X.
91. I cannot say what would have happened if the Care Provider had not acted with fault. But I consider had it paid more attention to Mrs Y’s hydration, her overall presentation due to a combination of illness or called an ambulance sooner, she may have become less ill or stood more chance of recovering. So, while Ms X will never know if the outcome could have been different for her mother, she will have the reasonable belief that it may have been. We consider for her to carry that uncertainty with her is also an injustice.

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Agreed action

92. To remedy the injustice identified above the Care Provider has agreed that within 20 working days of this decision, it will:
1. provide an apology to Ms X accepting the findings of this investigation and in line with our guidance on remedies (section 3.2); Guidance on remedies - Local Government and Social Care Ombudsman
2. provide a refund to Mrs Y’s estate of two weeks’ care fees in recognition of the poor care she received (£2800);
3. provide a symbolic payment of £500 to Ms X in recognition of her distress.
93. In addition, the Care Provider has committed to a series of service improvements arising from this complaint. Within three months it will write to us having completed:
1. a further investigation to understand why there were multiple failings and discrepancies in record keeping identified in this case – around hydration records, care of Mrs Y’s leg injury and contact with the GP. It will produce an action plan explaining how it will seek to avoid any repeat;
2. a review its expectations for Care Homes when it comes to monitoring residents who are ill. We want assurance the Care Provider can accurately record symptoms and keep those under review, along with any treatment plan which it may develop. It should review any guidance it publishes to its care homes in this area including when outside medical advice should be sought. It should advise if it has updated this, or proposes to do so, following the review;
3. a review of its expectations for Care Homes when it comes to recording communications with resident’s next of kin, especially when informing of significant events such as falls or a deterioration of health. It should review any guidance it publishes to its care homes in this area and advise if it has updated this or proposes doing so following the review;
4. a review of the training and materials it currently provides around sepsis awareness. It should advise if it has updated this, or proposes doing so, following the review.
94. Also, within three months of the decision, the Care Provider has agreed to ensure:
1. all staff at the Care Home have received training and / or refresher training to cover the Care Provider’s expectations when it comes to record keeping and policy for the management of hydration needs, wounds, contacts with health professionals and next of kin;
2. all senior staff at the Care Home have completed the Care Provider’s sepsis awareness course.
95. The Care Provider will provide us with evidence it has complied with the above actions.

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Final decision

96. For reasons set out above I uphold this complaint finding fault by the Care Provider caused injustice to Ms X and Mrs Y. The Care Provider has agreed to take action that I consider will remedy that injustice. Consequently, I have completed my investigation, satisfied with its response.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman