Summary: Mrs B complained about the care her late father received at one of the Provider’s care homes. There was fault in the Care Home’s record-keeping and its complaints handling, causing distress and uncertainty to Mrs B about the care her father received. It has agreed to apologise to Mrs B and reduce the amount she owes for Mr X’s care. It also agreed to review its processes and ensure its staff follow its policies and procedures.

The complaint

1. The complainant, whom I shall refer to as Mrs B, complained on behalf of herself and her late father, Mr X. She said the Care Provider:
• failed to provide a reasonable standard of care and skill when Mr X was in its care;
• failed to respond properly to her complaint and provide the forms and charts regarding Mr X’s care that she asked for; and
• wrongly asked Mrs B to pay for Mr X’s care during the period of his hospital admission and for a cancellation period.
2. As a result, Mrs B said Mr X experienced pain and distress. Mrs B said she also experienced distress because of the Care Home’s handling of the matters.

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The Ombudsman’s role and powers

3. 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)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. We normally name care homes in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home. (Local Government Act 1974, section 34H(8), as amended)
6. We normally expect someone to complain to the Care Quality Commission about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended)
7. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (section 26A or 34C, Local Government Act 1974)
8. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.
9. If we are satisfied with a care provider’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

10. As part of this investigation, I have considered:
• Mrs B’s complaint and the information she provided;
• the Care Home’s response and the information it provided, including its cancellation and care policies;
• Mr X’s Care Plan;
• the LGO’s Guidance on Remedies; and
• Mrs B’s and the Care Home’s comments on a draft version of this decision.

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What I found

Fundamental Standards of Care

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall. The standards include:
• Person-centred care (Regulation 9): The service user must have care or treatment that is tailored and meets their needs and preferences. Providers must involve a person acting on the service user’s behalf in the planning of their care and treatment.
• Safe care and treatment (Regulation 12): Providers must do all that is reasonably practicable to mitigate risks to the service user’s health and safety. The provider must have arrangements to take appropriate action if there is a clinical or medical emergency.
• Safeguarding from abuse (Regulation 13): Service users must be protected from abuse and improper treatment, this includes neglect.
• Food and drink (Regulation 14): Service users must have enough to eat and drink to keep them in good health while they receive care and treatment.
• Receiving and acting on complaints (Regulation 16): Providers must investigate complaints received and necessary and proportionate action must be taken in response to any failure identified. The Provider must have an effective system in place to handle complaints by service users and other persons.
• Good governance (Regulation 17): Providers must maintain securely an accurate, complete and contemporaneous record in respect of each service user.

What happened

12. Mr X had an indwelling urethral catheter due to urinary retention. He also had dementia and required assistance in all areas of daily living. Mr X’s daughter, Mrs B, held a Power of Attorney to support Mr X with his health, welfare and financial matters.
13. In early 2019 Mr X moved to the Oakland’s House Nursing Home (the Care Home), which is a residential care home operated by London Residential Healthcare limited.
14. A care plan was made for Mr X’s care in the Care Home, which said:
• he should have thickened fluids, food should be cut up and he should be offered food and drink throughout the day;
• for the first two weeks of admission to the Care Home, he should be encouraged to drink at least 1400mls by 14.00 each day and continue to take fluids afterwards. His daily intake should be calculated and recorded daily, and any shortfalls should be communicated to the Care Team and his GP. The Registered Nurse should then calculate Mr X’s daily average fluid intake and use this amount as an aim for his 24-hour fluid intake;
• care staff should fully assist Mr X to care for his catheter as he is unable to do so himself, including twice daily washing and drying of the catheter area, recording daily fluid intake and urine output, monitor blockages and signs of infection. Concerns about infection should be promptly referred to his GP; and
• he should have his catheter changed routinely changed every three months.
15. In December 2019 Mr X was admitted to hospital because of re-catheterisation issues and a urinary infection.
16. The Care Homes records for the day says Mr X was given personal care at 11.30am where his bed was found wet and he said he was in pain. An hour later, the registered nurse attended and found the catheter blocked. The catheter was changed but only a small amount of urine came down. Mr X continued to be in pain and the nurse took a sample of the urine and checked his bowels. Four hours later, the nurse contacted Mr X’s GP who asked for two suppositories to be given in case of constipation. However, Mr X continued to be in pain and passed blood with his urine. Three hours later the nurse called the out of hours GP and was informed they would call back. Around 9.30pm, the call back was received. The GP advised that Mr X could be seen in two hours or if necessary, call the emergency services. The nurse called the emergency services and also contacted Mrs B. Mr X was subsequently admitted to hospital.
17. The following day Mrs B called the Care Home to raise her concerns about the care it provided to Mr X. She also asked why his clothes and toiletries had not been sent with him to the hospital.
18. Mr X stayed in hospital for four weeks. Mrs B says because of the Care Home’s treatment of Mr X, he did not want to return to the Care Home. When he was discharged from hospital Mrs B went to the Care Home to collect his things. She said she asked to speak to the Care Home manager but was told the manager did not have the information needed available. Mrs B said she was told the manager would investigate and provide a response.
19. After release from the hospital, Mr X moved to a different care home without giving cancellation notice to the Care Home.
20. The Care Home sent a letter to Mrs B. It said it required payment of the period when Mr X was in hospital and for a further 4 weeks because Mr X had left the Care home without providing the required notice.
21. Mrs B did not pay. She said she had not received a response to her complaint. And so, she complained again to the Care Home. She said:
• Mr X had been unhappy for a while in the Care Home because of rough treatment, including rudeness;
• weekly eye test for Mr X had not been completed as required;
• the standard of care and skill provided to Mr X was not a reasonable standard;
• it had failed to provide information and respond to her concerns about his care and catheterisation prior to his hospital admission; and
• its high use of agency staff can affect the continuity of care.

Mrs B asked the Care Home for a price reduction because of its failures.

22. Three weeks later, Mrs B contacted the Care Home again because she had not received a response to her complaint. It told her the manager had left the Care Home and it would respond within a week.
23. The Care Home responded to Mrs B’s complaint. It apologised for the lack of responses to previous emails. It said it could not comment on the fact Mr X was unhappy at the Care Home or the previous manager’s meeting with Mrs B. However, it said it had investigated the events that took place on the day of the admission and attached a timeline of the actions taken, including some of Mr X’s care charts.
24. Mr X died in March 2020.
25. Mrs B was unhappy with the response and complained again to the Care Home. She said it had failed to respond properly to her complaint. She said the information and charts it provided raised further concerns. She asked the Care Home:
• how it dealt with Mr X’s low intake of fluid and urine output on several days during the month prior to his hospital admission;
• why some records and monitoring were not completed and signed off;
• to explain the events and actions taken when catheterising Mr X; and
• to respond to her original complaint and request for a price reduction.
26. A month later, the Care Home told Mrs B it was unable to respond due to circumstances related to COVID-19. It said it would respond when it was able to do so.
27. The Care Home continued to ask Mrs B for payment of the outstanding fees. Mrs B informed the Care Home’s finance person about her complaint and asked for her complaint to be referred to a senior manager.
28. In July 2020, Mrs B had not received a response and so she again asked the Care Home to respond to her complaint and provide the information requested.
29. On the same day, the Care Home manager responded. She told Mrs B that should respond in full later in the week.
30. Mrs B said she has still not received a response from the Care Home and so she complained to the Ombudsman.

My findings

31. I have reviewed the Care Home’s records for Mr X’s care from November 2019 to December 2019.

Reasonable care and skill

32. Mrs B said Mr X was unhappy about his stay in the Care Home prior to his hospital admission because of rough treatment and rudeness. However, I have seen no evidence of this. In addition, if Mr X was unhappy in the Care Home, he or Mrs B was free to give the required cancellation notice and find an alternative care home. Based on the information available, I therefore have not found fault by the Care Home in this matter.
33. Mrs B questioned the standard of care and skill provided to Mr X during the month of November until his hospital admission. In particular, in relation to his catheterisations, the Care Home’s actions to monitor and care for Mr X during this period and its actions on the day of his admission to hospital.
34. The records provided by the Care Home shows it provided Mr X with food and drink at regular intervals. It also provided personal care and completed daily charts and monthly risk assessments in line with his care plan.
35. However, the records also show Mr X was catheterised six times over a one-month period. Mr X’s care plan said this should occur once every 3 months and any concerns, such as pain, should be reported to his GP. I have seen no evidence that Mr X’s GP was informed about this during the period. This only occurred shortly before his admission to hospital. Also, Mr X’s care plan says he lacked capacity and Mrs B held a Power of Attorney to support him with his health and welfare, I would therefore have expected for her to be told about his catheter problems by the Care Home. This is fault.
36. In addition, based on the evidence provided, the Care Home’s policies covering fluid intake, urine output and monitoring following catheterisations of Mr X were not followed as required from November 2019 to December 2019. This is fault. The information provided by the Care Home shows:
• several charts were not fully completed, nor signed by a registered nurse as required by the Care Homes Policy;
• Mr X’s fluid intake and urine output were below the expected standards as set out in Mr X’s care plan and the Care Home’s policy. There is no evidence that Mr X was placed on the additional measures available to prevent dehydration or infection;
• Mr X did not have bowel movement for three days prior to his hospitalisation. This was four days after his last catheterisation. There is no evidence that this had been observed or acted on by the care home in line with its post catheterisation procedure; and
• Mr X’s care plan says his catheter was size 14. However, the daily notes show he was catheterised with a smaller size 12.
37. The Care Home provided its records of the day Mr X was hospitalised. This shows he told it he was in pain. The Care Home and its registered nurse supported Mr X and attempted to resolve his pain throughout the day. It contacted his GP and an out of hours GP to seek support and followed the advice given. When Mr X was in excessive pain and the out of hours GP advised for it to call emergency services, it followed the advice given and contacted Mrs X. I have not found fault by the Care Home on this matter because it supported Mr X throughout the day and sought the relevant support from GP and the emergency services.

Complaints handling and providing information

38. The fundamental standards require the Care Home to have an effective system in place to investigate, handle and respond to complaints. This includes keeping accurate records to enable it to respond fully and proportionately to complaints.
39. Mrs B complained to the Care Home in December 2019. The Care Home provided a response three month after, but this did not address key parts of her complaint. When she complained again and asked for information, the Care Home said it could not respond due to COVID-19. Then, seven months after her first complaint, the Care Home promised to provide a response. However, to date this has not been received.
40. Although I acknowledge the Care Home’s change of management could cause a delay, it is required to maintain records to enable it to respond to complaints. I therefore find there was fault in the Care Home’s record keeping and complaints handling process, which caused and is continuing to cause Mrs B distress and uncertainty.

Charging for Mr X’s care

41. Mrs B said she should not be required to pay the fees to the Care Home for Mr X’s care during his hospital admission and the 28-day cancellation period because of its failure to provide Mr X with a reasonable standard of care and skill.
42. The agreement between Mrs B and the Care Home provides the terms and conditions applicable. The agreement says service users remain liable for the costs of the Care Home during hospital admissions. It also says that there is a 28-days’ notice period to cancel the agreement. This is the period the Care Home is asking Mrs B to pay for. Mrs B is therefore contractually obliged to pay this amount.
43. Although I have found faults by the Care Provider, I cannot say these amounted to a failure to provide Mr X with a reasonable standard of care and skill, and thereby invalidate the contract with the Care Home. Such matters are for the courts to decide. If Mrs B is not happy with the remedy I have provided for the injustice caused, she can bring the matter to a court for its consideration.

Injustice

44. While the Care Home’s failure has left Mrs B feeling let down and distressed about the care Mr X received at the Care Home, I cannot say if this contributed to his untimely death. As Mr X has died, it is not possible to remedy the injustice caused to him. However, it is possible to remedy the injustice to Mrs B for the avoidable distress and uncertainty she has been caused by the Care Home’s poor record keeping, failure to provide the information she asked for and its complaints handling.
45. I am satisfied that Mrs B has experienced distress and uncertainty from these failures, including for the time and trouble she has been put through in pursuing the complaint. It is therefore appropriate to reduce the amount Mrs B is required to pay for Mr X’s care costs to the Care Home.

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Agreed action

46. I have considered the Ombudsman’s Guidance on Remedies. To remedy the injustice caused Mrs B, the Care Home has agreed to, within one month of the final decision:
1. Apologise to Mrs B for its delay, poor record keeping, failure to respond to her complaints, and failure provide the information she asked for;
2. Reduce the outstanding fees due from Mrs B by £2,000 for the avoidable distress caused by the uncertainty about whether failures in care had led to her father’s infection and decline in health;
3. Pay Mrs B £150 for her time and trouble in pursuing the complaint.
47. Within three months of the final decision the Care Home should also:

d) Review its processes and remind staff to ensure policies are followed and it keeps adequate records, in particular for:

• Catheterisation and subsequent monitoring of service users;
• keeping GP’s and relevant family members informed about service user concerns; and
• complaints handling.

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Final decision

48. There was fault leading to injustice. The Care Home has agreed to my recommendations. Therefore, I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman