Summary: We investigated a complaint about the care provided to Mrs F. We found fault with the Nursing Home who did not keep accurate records. This caused confusion to Miss E about whether she could have avoided infection. We recommended an apology and service improvements, but the Nursing Home has closed and we cannot enforce compliance with our recommendations. We found no fault with the Council or the Trust.

The complaint

1. Miss E complains about the care and treatment her mother, Mrs F, received from Suffolk County Council (the Council) and West Suffolk NHS Foundation Trust (the Trust). She also complains about the care Mrs F received while at Pinford End Nursing Home (the Nursing Home). Specifically, she complains;
• Mrs F was medically fit for discharge on 21 July, but she did not leave hospital until 12 days later.
• Mrs F went to the Nursing Home because the Council could not arrange a suitable package of care to allow her to go home.
• The Council has not provided a clear explanation of what it did to help Mrs F return home in early September 2021.
• The Council cancelled a Care Act assessment at the last minute and did not complete it until 16 days after Mrs F went into the Nursing Home.
• The Nursing Home did not act quickly when Mrs F was showing signs of a urinary tract infection and did not encourage her to drink.
• The Nursing Home missed opportunities to reduce the risk of Mrs F falling, which she did on 20 September 2021. It has provided contradictory answers in its complaint responses.
2. Miss E says if the Council had sourced a suitable home care package sooner, her mother would not have died when she did. Miss E worried about her mother while she was in the Nursing Home and feels it should have done more to keep her safe. These actions caused Miss E distress seeing her mother decline so quickly.
3. Miss E would like an apology, service improvements and a symbolic payment to recognise the distress she suffered.

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The Ombudsmen’s role and powers

4. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015 a single team has considered these complaints acting for both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
5. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship. (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended)
6. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation acts to stop the same mistakes happening again.
7. The Ombudsmen cannot question whether a decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the organisation reached the decision. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
8. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

9. I considered the complaint Miss E made to the Ombudsmen and information she provided by email. I also considered the information the Council, the Trust and the Nursing Home provided in response to my enquiries.
10. I shared a confidential draft with Miss E, the Council, the Trust and the Nursing Home to explain my provisional findings and invited their comments on them. I considered all comments before making a final decision.

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What I found

Delays in leaving hospital

11. Miss E complains there was a delay when Mrs F left hospital. She says the Council failed to arrange care at home for Mrs F so she had no choice but to go to the Nursing Home. Miss E asked the Council to explain what attempts it made to arrange the care but said it has not been clear.
12. I asked the Trust to explain when Mrs F was ready to leave hospital, and if there was a delay from her being ready to her leaving. The doctor said Mrs F was well enough to leave hospital on 21 July, and the same day the Trust sent a referral to the Council explaining what care Mrs F would need.
13. Miss E spoke to a social worker from the Council on 22 July as she had concerns about the care agency who cared for Mrs F before she went into hospital. The social worker explained the care agency could no longer support Mrs F because her needs had changed, so they would need to find a new one. Miss E also asked the social worker if Mrs F could go into an interim bed in a care setting to give her more time to recover before she went home. The social worker said they could look into this option, but Mrs F would need to agree.
14. The social worker told the Trust on 23 July the Council needed to find a new care agency before Mrs F could go home. On 26 July, the social worker visited Mrs F in hospital. The social worker told Miss E she worried how Mrs F would cope at home on her own in between care visits. Miss E also started to make changes to Mrs F’s home so she could live with her when she returned home.
15. On 29 July, Miss E told the social worker Mrs F had agreed to an interim stay. Unfortunately, Miss E’s preferred choice of home was no longer available so she agreed the social worker could contact Pinford End Nursing Home. The Nursing Home agreed it could care for Mrs F, but not until 3 August. The social worker told Miss E this, and a note says she is happy her mother would leave hospital on 3 August.
16. Mrs F moved to the Nursing Home on 3 August.
17. In summary, the Council could not start arranging care for Mrs F until after the Trust told it what Mrs F’s needs were. We would not expect the Trust to discharge a patient without care arrangements in place, and the evidence shows Miss E and the social worker worked together to arrange the best option for Mrs F. Mrs F agreed to go to an interim care placement on 29 July. Unfortunately, due to staff shortage, she could not go to Pinford End Nursing Home until 3 August.
18. There was a delay in Mrs F leaving hospital from when the doctor said she could, but this was not because of fault by the Council in arranging her care.

Council action from September 2021

19. Mrs F went to the Nursing Home to allow her to recover while the Council arranged home care. Miss E asked the Council what it did to arrange the care but said it has not been clear with her. Miss E said she spoke to a care agency who cared for Mrs F’s neighbour, and it said they could help Mrs F. I have seen no mention of this care agency in the Council’s records so I cannot reconcile what happened with this information.
20. Mrs F’s stay at the Nursing Home was due to end on 1 September. I asked the Council to explain what action it took to find Mrs F support for her to go home.
21. From 23 August, the Council’s Placement team contacted local care agencies to see if they could support her. I have seen evidence the Council contacted 39 care agencies, and all could not offer support to Mrs F. Some agencies said to check later in September, so the Council decided to extend Mrs F’s stay in the Nursing Home. Unfortunately, Mrs F fell on 20 September, and went to hospital.
22. On 6 October the Council recognised Mrs F needs had increased and again tried to contact care agencies to support her. On 21 October the Council asked Home First, who agreed it could help Mrs F from 27 October.
23. Miss E feels the Council should have done more to help Mrs F return home. She feels she would have had a better quality of life had she done so, and she may not have had the fall. I can understand why Miss E felt the Council were not helping Mrs F as she did not know the work it was doing.
24. I have seen evidence the delays in arranging support for Mrs F were because of a lack of availability not because of lack of action. I can find no indications of fault with the actions of the Council.

Care Act assessment

25. Miss E complains the Council cancelled Mrs F’s Care Act assessment at the last minute and then it did not complete it until 16 days after she went to the Nursing Home.
26. Mrs F went into the Nursing Home on 3 August, and an assessment was booked for 10 August. The Council later explained the assessor was unwell and it had to cancel the assessment. A social worker left a voicemail for Miss E to explain this and explained it would re-book the assessment soon. Miss E said she did not receive a call and only found out because she was at the Nursing Home and a member of staff told her it had been cancelled. The Council completed the assessment on 19 August.
27. While it is unfortunate the Council had to cancel the first appointment, the records show it left a message for Miss E, but she disputes this. She did however find out from staff at the Nursing Home and the appointment re-booked quickly.
28. There is no set timescale for how long someone should wait for an assessment. Guidance advises professionals to assess needs when a person is settled and when the Council is satisfied, they are receiving care that meets their needs in the interim. Therefore, I cannot find any indications of fault.

Complaints against Nursing Home

Urinary tract infection

29. Miss E complains staff did not act quickly when Mrs F showed signs of a urinary tract infection and did not encourage her to drink.
30. Mrs F’s care plan from 4 August 2021 states staff should “encourage fluids to promote a good urine output and prevent infections”.
31. Mrs F’s daily records do not show what fluids she was offered, and whether she accepted drinks or not. I asked the Nursing Home if it had fluid charts for Mrs F and it confirmed it did not.
32. The Care Quality Commission Regulation 17: Good governance states “17(2)(c) records relating to the care and treatment of each person using the service must be kept and be fit for purpose. Fit for purpose means they must: be complete, legible, indelible, accurate and up to date”.
33. Mrs F’s care plan tells Nursing Home staff they need to encourage her to drink, but because there are no fluid charts, neither the Nursing Home or the Ombudsmen can tell how often she was offered a drink, or how much she drank on any day.
34. Miss E believes the urine infection Mrs F had in the Nursing Home could have been avoided had staff given her enough to drink. This is an injustice to Miss E because she worried about her mother when she should have been reassured she was receiving good care.
35. This is fault which caused an avoidable injustice to Miss E.

Fall on 20 September 2021

36. Miss E complains staff missed opportunities to reduce the risk of Mrs F falling. When she complained about this to the Nursing Home directly, it provided answers which left her unclear about what happened.
37. Mrs F’s admission form states she is “able to show insight on ward and is not taking risks”, it adds she is “able to use call bell”. An undated falls risk assessment which states it was completed on admission, scores her as medium risk and there is a list of guidance actions for staff to be aware of.
38. On 20 September 2021, Mrs F fell outside another resident’s room, and they pressed their call bell to alert staff. Her daily notes explain staff responded to an emergency buzzer and staff found Mrs F on the floor. The notes explain staff checked her for injuries and she said she had a lot of pain in her left leg and hip and a headache. Staff called an ambulance which took Mrs F to hospital with a suspected dislocated hip. Staff contacted Miss E who went to the hospital and later told staff Mrs F also had a fractured femur which needed surgery.
39. The incident report form explained staff “had gone to the get the tea trolley when it happened”, and Mrs F “said she was going to work when they found her on the floor”.
40. Staff knew Mrs F was at risk of falls. Miss E wants to know why the Nursing Home did not take more precautions as there were four previous incidents of her walking alone, I cannot find any mention of these incidents in Mrs F’s records so while I do not dispute what Miss E has said, I cannot reconcile her account with the records. The fall on 20 September was the only time she fell while at the home. Staff were not instructed to keep her under observation or restrict her movement.
41. I can understand why Miss E is unhappy Mrs F fell, but I cannot see this is because of lack of action by staff. It was an isolated incident which was out of character for Mrs F and there was no way staff could have predicted she would behave in such a way. I therefore cannot find any indications of fault.

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Recommendations

42. The Ombudsmen made the following recommendations but the Nursing Home has ceased to operate, so we cannot achieve a remedy for Miss E.
43. We recommended:
44. Within one month of the date of the final decision, the Nursing Home should write to Miss E and apologise for the distress and uncertainty it has caused her by not keeping accurate records, meaning she does not know what fluids her mother received and whether the urine infection could have been avoided. It should send a copy of this letter to the Ombudsmen. Miss E told the Ombudsmen an apology is not acceptable so in this case we have decided not to pursue the managers of the Nursing Home for an apology directly.
45. Within two months of the date of the final decision, the Nursing Home should send a briefing note to all staff reminding them of the importance of accurately recording fluids given to residents when it is indicated in their care plan that urine infections are a risk factor. It should also consider introducing fluid charts for such patients. It should send evidence of this to the Ombudsmen. Because the Nursing Home is now closed, there is no realistic way or benefit to the Ombudsmen pursuing this remedy.

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Final decision

46. I partly uphold the complaint. I found fault by the Nursing Home which caused an avoidable injustice to Miss E. As the Nursing Home has ceased to operate, I cannot remedy this injustice. I found no fault with the Council or the Trust.

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Investigator's decision on behalf of the Ombudsman