Summary: Mr D complained about the care and support provided to his late mother, Mrs G, when she was discharged from hospital to a care home. We did not find fault by the Trust or the Council. There was fault in the way the Home recorded Mrs G’s weight and it failed to refer her for a continence assessment. The Home agreed to our recommendations to apologise to Mr D and Mr G and make symbolic payments.

The complaint

1. The complainant, who I shall refer to as Mr D, complains about the care and support provided to his late mother, Mrs G, when she was discharged from hospital to an interim placement at Queensferry Court Care Home (the Home) in
   December 2021. He also represents the complaint on behalf of his father Mr G.
2. Mr D says, University Hospitals of Derby and Burton NHS Foundation Trust (the Trust) and the Home did not work together to ensure his mother was provided with sufficient health care in the community following her discharge. He says Derby City Council (the Council) did not ensure the Home met expected standards relating to his mother’s continence care and nursing needs. He also complains about a lack of therapy for his mother.
3. Mr D said the Home did not escalate a suspected infection to a relevant medical professional although he says it was apparent his mother was acutely unwell. He feels a lack of action by the organisation especially the Home contributed to his mother’s death in January 2022. To put things right he wants the organisation to admit fault and compensate him and his father.

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The Ombudsmen’s role and powers

4. 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).
5. 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 takes action to stop the same mistakes happening again.
6. When investigating complaints, if there is a conflict of evidence, the Ombudsmen may make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
7. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of, for example, the impact of poor care that person might have received while they were alive. This is because the person who received the poor care cannot benefit from such a payment. However, if we consider the person who has complained to us has been adversely affected by seeing the impact of that poor care on their relative, we may recommend a symbolic payment to them as a remedy for their own distress.
8. A decision about what a suitable remedy should be for a complaint is one for us to decide. Each case is considered on its own merits. Our Guidance on Remedies for staff sets out the general principles that investigators should apply when deciding what recommendations to make.
9. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
10. 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

11. I have considered from the organisations complained about in response to my enquiries also information from Mr D provided in writing and by telephone.
12. All parties had an opportunity to respond to a draft of this decision. I have considered the responses before reaching a final decision.

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What I found

Legal and administration context

13. Discharge to assess (D2A) is about funding and supporting people to leave hospital, when safe and appropriate to do so, and continuing their care and assessment out of hospital. Under Pathway 2 patients are discharged to residential care with the independent and community sector for further assessment.
14. 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.
15. The CQC is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.

Background

16. Mr D’s late mother, Mrs G, lived with her husband Mr G and her son in the community. She went into hospital in December 2021 because of reduced mobility and increased falls associated with urinary incontinence.
17. Before being discharged from hospital the Trust moved Mrs G to a Discharge Assessment Unit (DAU). Following a short time in the DAU Mrs G was discharged to the Home at the end of December under discharge to assess arrangements funded by an Integrated Care Board. The Council was responsible for monitoring the placement and the quality of care provided by care providers when people were placed in interim bed placements.
18. Mrs G remained in the home until January 2022 and received visits from Mr D and Mr G during this time. During the same month Mrs G passed away. Mr D then complained about the organisations involved in his late mother’s care.

Findings

The Trust’s involvement in the discharge to assess process

19. The Trust completed an initial assessment to inform the discharge to assess referral. This was while Mrs G was on the DAU. The assessment noted that
    Mrs G needed a pathway two inpatient rehabilitation bed. It recorded that Mrs G had had “a recent deterioration in memory and mobility resulting in falls”. In this case Mrs G needed the assistance of one person with transfers.
20. The assessment also recorded Mrs G had problems with “constipation and urinary incontinence”. She wore incontinence pads to help manage this with the assistance of one person to manage personal care tasks. The Trust also recorded that Mrs G showed symptoms of an undiagnosed dementia.
21. The Trust gave the Home a copy of the discharge to assess form so the Home could use this to inform its assessments and care and support arrangements while Mrs G was in the interim bed.
22. When Mr D complained to the Trust part of his complaint included what he said the Home confirmed the organisation responsible for his mother’s medical care needs. Mr D said the Home told him his mother remained under the care of the hospital after she was discharged to the interim placement.
23. In response to Mr D’s complaint the Trust said once a patient is discharged their ongoing care then becomes the responsibility of the home and the local general practitioner (GP) assigned to that specific home.
24. In response to our enquiries the Council confirmed Mrs G was discharged from hospital under discharge to assess arrangements funded by an Independent Care Board (ICB). The Council said its social work team would have supported the discharge as part of a multiagency hospital team.
25. The Council said the ICB had an arrangement in place with the Home where people in interim beds were temporarily registered with another GP. This was under an agreement between the ICB, and the care homes used for interim beds.
26. The evidence available suggests it is more likely than not the Trust did not have responsibility for medical needs Mrs G might have had once she was discharged to the interim placement bed in the community. Mrs G was medically fit for discharge, and it is more likely than not the Home would have been responsible for monitoring Mrs G’s need for medical attention so it could contact health professionals as necessary. Therefore, I do not find the Trust at fault in this regard.

The care and support the Home provided to Mrs G

27. The Council and the Trust arranged Mrs G’s discharge from hospital to the Home under discharge to assess arrangements. The placement was funded by the relevant health authority. Because of the way the funded arrangements worked Mrs G was placed in a particular section of the Home used for health funded temporary placements.
28. The Council worked as part of an integrated hospital discharge team. It was also responsible for investigating any concerns falling under its wider monitoring and safeguarding role. It dealt with a complaint from Mr D and investigated his concerns about the Home.
29. Mr D said his mother was kept in the same room during her stay and was not moved to covid free part of the Home once she was out of isolation. The Home explained that Mrs G was in a part of the home which had beds reserved for temporary placements. The Home was entitled to make this decision.
30. Mr D specifically complained about the way the Home monitored his mother’s weight, provided continence care and how it should have communicated with external health professionals.
31. Mrs G went into the Home at the end of December 2021 and the Home said it monitored her weight on three different dates in January 2022. However, it said a trainee staff member had recorded Mrs G’s weight incorrectly to show that she had lost more weight than she had. Mr D did not agree with the Home’s account.
32. Further investigation by the Ombudsmen is unlikely to establish what Mrs G’s weight was at the time. The information provided by the Home is evidence of poor recording which is not in line with the Care Quality Commission’s fundamental standards. This fault is likely to leave Mr D and Mr G with uncertainty about whether his mother had lost weight due to poor nutrition and fluid intake.
33. The discharge plan from the hospital noted that Mrs G had continence needs. She needed to wear a pad and needed the assistance of one carer to assist her with personal care. The Trust also said she showed symptoms of an undiagnosed dementia.
34. Mr D said he had a phone call with his mother’s doctor in January and the doctor referred his mother to the memory clinic. Mr D said he spoke to the memory clinic but it did not progress the tests requests by the doctor.
35. During the Council’s investigation it found there were two instances when the Home said Mrs G had refused to have her wet pads and wet sheets changed. The Home was aware Mrs G displayed symptoms which could have affected her capacity to make specific decisions. The Home should have considered Mrs G’s capacity to make the decision to stay in wet incontinence pads and to lay on wet sheets.
36. The Home had a responsibility to ensure Mrs G received care in a personalised and dignified manner. I have not seen evidence to show the Home did this on these two occasions and this is fault. This is likely to cause Mr D and his father avoidable distress and lead them to question the standard of care Mrs G received in the Home.
37. Mr D complained the Home did not take responsibility for his mother’s medical needs by ensuring it liaised with a GP. The assessment completed by the Trust when Mrs G was discharged from hospital did not note any ongoing medical needs except for those listed on the discharge to assess form.
38. The documentary evidence shows that Mrs G received therapy input to help with mobilising during the time she was in the Home. She also received visits from the community nurse. Therefore, I cannot say Mrs G did not receive therapy.
39. The Home said it did not identify any infections or reasons to escalate concerns to a relevant health professional while Mrs G was in the Home. Mr D questioned the account provided to the Home’s staff to his mother’s GP after she had died. He said he saw his mother five days before she passed away and she could not support her own body weight. The Council and the Home said Mrs G had regular visits from the community matron when she was in the Home. On the evidence available now, I cannot say how unwell Mrs G was during the five days before she passed away.
40. During the period of Mrs G’s placement in the Home the Council’s officer contacted the Home and asked it to arrange a continence assessment for
    Mrs G. The Home cannot provide evidence to show it actioned the request. This is fault. This is likely to cause uncertainty for Mr D and Mr G about the care
    Mrs G received.
41. Mr D also complained about his mother’s wedding ring going missing while she was in the Home. The Home said it did not receive a property Trust when Mrs G was discharged. In response to our enquiries, the Home could not provide an inventory of items it should have completed when the placement started. This is fault. I cannot say what happened to Mrs G’s ring but the failure of the Home to complete an inventory form is likely to cause Mr G and Mr D to experience uncertainty and avoidable distress.

Conclusion

42. The Trust was not responsible for monitoring Mrs G’s medical needs after she was discharged from hospital. Therefore, I do not find the Trust at fault.
43. The Council undertook an investigation and completed quality audits after Mr D raised complaints. I do not find fault by the Council. The audits included the Council monitoring the Home and the overall care and support it provided. This is likely to have led to service improvements. Therefore, we do not need to make further recommendations for improvement.
44. Faults by the Home are likely to have caused Mr D and his father to experience avoidable distress and uncertainty about the care Mrs G received while in the interim placement. They are also likely to have experienced uncertainty about what happened to Mrs G’s wedding ring because the Home failed to complete a record of Mrs G’s personal belongings when she entered the Home.

Our approach to remedies

45. Mr D said he would prefer a letter from the Home acknowledging overall bad practice and neglect. The Home agreed with my findings and accepted it was at fault as identified within this decision statement.
46. We found fault causing injustice and in line with our remedies guidance, I recommended the Home apologise to Mr D and Mr G and make symbolic payments. The Home agreed to our recommendations when responding to our draft decision. Mr D said he and his father feel an apology is too late and they do not want a symbolic payment. It is unlikely we could achieve more.

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Final decision

47. There is fault by the Home which caused injustice to Mr D and Mr G which the Home accepted. I uphold Mr D’s complaint against the Home and I have completed the investigation.

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Investigator's decision on behalf of the Ombudsman