Summary: Mr X complained about the care received by his father, Mr F, when he was at Ashley Lodge Care Home. The Care Provider and Council have already admitted some of the record-keeping was poor. The Council should ensure staff at the Care Home are reminded of the importance of accurate record keeping to prevent any future reoccurrence of this fault.

The complaint

1. Mr X complains Ashley Lodge Care Home:
1. placed Mr F in the dementia unit on his admission to the care home although he did not have dementia;
2. wrongly classed Mr F as ‘non-mobile’ and failed to provide rehabilitation as agreed by the hospital using the equipment Mr F was discharged with;
3. did not have a clinical staff member in the role of care home manager;
4. failed to take adequate measures to prevent the spread of COVID-19 at the Care Home, leading to Mr F contracting COVID-19;
5. failed to keep accurate records and/or provide adequate care relating to Mr F’s catheter, pressure sore, food and fluid intake, weight, oral hygiene, medication, oxygen intake and allergies;
6. failed on one occasion to response in a timely manner when Mr F pressed his buzzer for help;
7. did not inform the family when he became ill with a raised temperature and was diagnosed with suspected COVID-19;
8. failed to take steps to obtain his sister’s number who was next of kin, when it became apparent the number recorded by the care home was wrong;
9. lied when it told the family it had called 111 about his temperature; and
10. refused to provide documents requested by his father via email.
2. Mr X also complains the Council discharged Mr F from hospital into Ashley Lodge, a care home which was classed as inadequate by the Care Quality Commission (CQC) and was unable to meet Mr F’s needs.
3. Mr X says that as a result, Mr F was not provided with the care he required and he contracted COVID-19, leading to his death.

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What I have investigated

4. I have investigated all of Mr X’s complaints except for the complaint in paragraph 1j). I explain why I have not investigated this complaint at the end of this decision statement.

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The Ombudsman’s role and powers

5. This complaint involves events that occurred during the COVID-19 pandemic. The Government introduced a range of new and frequently updated rules and guidance during this time. We can consider whether the care provider followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”.
6. We have powers to investigate adult social care complaints in both Part 3 and Part 3A of the Local Government Act 1974. Part 3 covers complaints where local councils provide services themselves or arrange or commission care services from social care providers, even if the council charges the person receiving care for the services. We can by law treat the actions of the care provider as if they were the actions of the council in those cases. Part 3A covers complaints about care bought directly from a care provider by the person who needs it or by a representative, and includes care funded privately or with direct payments under a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
7. In this case the Council arranged Mr F’s care. Therefore, we will treat the actions of the care home as if they were the actions of the Council.
8. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
9. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
10. If we are satisfied with a council’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)
11. The Information Commissioner's Office considers complaints about freedom of information. Its decision notices may be appealed to the First Tier Tribunal (Information Rights). So where we receive complaints about freedom of information, we normally consider it reasonable to expect the person to refer the matter to the Information Commissioner.
12. 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.

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How I considered this complaint

13. I spoke to Mr X and considered his view of his complaint and the information he provided.
14. I made enquiries of the Council and considered the information it provided. This included Mr F’s discharge summary from hospital, all his care records, including medication charts, wound management and food and fluid records, COVID-19 procedures in place at the Care Home and complaints correspondence.
15. I wrote to Mr X and the Council with my draft decision and considered their comments before I made my final decision.

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What I found

Discharge to assess under COVID-19

16. From 19 March 2020, there was a requirement to free up hospital beds for the anticipated wave of COVID-19 admissions. Government guidance at that time ordered rapid discharge of all patients who were clinically ready to leave hospital, either to go home or to another place of care. Transfer from the wards was to take place within one hour to a designated discharge area and then discharge from hospital as soon as possible, and within two hours wherever possible.
17. For patients who needed to be discharged to a rehabilitation bed or care home, the guidance stated they would not be able to remain in hospital until their first choice of care home or placement had a vacancy. This meant some patients were discharged to an alternative care home until they were able to move to their preferred choice. The guidance stated the NHS would pay for this support. There was no guidance preventing councils from admitting people discharged in this way to care homes requiring improvement from the Care Quality Commission (the body which regulates care homes).

Fundamental Standards

18. 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.
19. Regulation 17 states providers must securely maintain accurate, complete and detailed records about each person using their service.

What happened

20. In March 2020, when the country went into lockdown due to the COVID-19 pandemic, Mr F was in hospital. At that time, he was medically fit for discharge.
21. Under the discharge to assess guidance introduced by the government, Mr F was discharged to Ashley Lodge Care Home. At its last inspection by the Care Quality Commission (CQC), the Care Home was deemed to require improvement in some areas.
22. Mr F’s discharge summary from the hospital included the following:
• he had experienced adverse reactions to certain medications;
• he had been assessed for rehabilitation and deemed suitable but due to the pandemic it was unsafe for Mr X to remain in hospital whilst waiting for a rehabilitation bed. Therefore, he had been discharged to Ashley Lodge Care Home in the interim;
• he was prescribed 1L of oxygen a minute when he was at rest increasing to 4L when mobilising; and
• the hospital Speech and Language Therapist (SaLT) recommended his food input was monitored.
23. The Care Home carried out an assessment and drew up a care plan. This recorded Mr F should:
• be cared for in bed;
• have his urine output monitored, twice daily catheter care carried out and his bag changed weekly;
• have his bowel movements monitored and recorded; and
• have his pressure sore reviewed and redressed by trained staff every three days.
24. Mr F’s care plan also recorded Mr F was at high risk of malnutrition.
25. Mr F remained in the Care Home until 16 April, when he was discharged home. By this stage, the GP had classified him at being at the end of life. He died on 25 April. The coroner’s report stated there were several causes of death, including COVID-19.

Mr X’s complaint

26. Mr X was unhappy with the care Mr F received at the Care Home and complained to BUPA (the Care Provider who owned the Care Home) and the Council. His complaints are listed in paragraph 1 and 2 of this decision statement. Both the Care Provider and Council provided detailed responses to Mr X, outlined below. In addition, some of the issues raised by Mr X were considered via a Council safeguarding investigation. These are also outlined below.

Response by the Care Provider

27. The Care Provider’s main response was in July 2020. It stated it had not acted with fault in the following areas and gave its reasons why:
• there was no legal requirement for a care home manager to be clinically trained;
• Mr F was not admitted to the dementia unit, but was placed in an area which had been specifically set up for residents who had been admitted from hospital and needed to isolate;
• the Care Home had not been informed by the hospital that Mr F would be able to receive physiotherapy in the Care Home. If the hospital had discussed this with the Care Home, the manager would have advised this could not be arranged because the Care Home was in lockdown and non-essential external visitors were not allowed. In addition, Mr F was unwell and needing nursing in bed. There was no evidence he could stand or mobilise;
• there were daily briefings during that period of the pandemic and issues such as handwashing and other infection control measures were constantly reiterated;
• Mr F’s daily notes recorded catheter care and bowel movements and a weekly plan of catheter care and bag changes was also in place. On 15 April, the GP had a virtual meeting with Mr F and a saline solution was prescribed to be used by a nurse to manage the procedure for bladder blockage;
• the Care Home had photographs of Mr F’s pressure sore at the start and end of the stay and these showed an improvement. Mr X’s photograph was taken ten days after Mr F had been admitted home in which time his pressure sore could have deteriorated. There was no evidence the Care Home provided inadequate care;
• when Mr F had a slightly raised temperature, the Care Home was unable to get through to his next of kin. Mr F then said he would speak to the family about it. Because Mr F had capacity, this was accepted by the Care Home; and
• the fact Mr X had been told by the local ambulance service that it had no record of a call was not evidence this had not taken place. Because of the pandemic, calls were often transferred to out of area ambulance services.
28. The Care Provider found fault in the following areas:
• the Care Home had not properly recorded Mr F’s allergies on his records. It apologised and noted Mr F had not come to any harm because of the error and that he had capacity and therefore would have been able to advise staff of his allergies if there had been a need;
• in the case of one of Mr F’s medications, the medicine administration recording (MAR) charts were misleading and appeared to show Mr F had been prescribed the medication twice. The Care Provider explained this was because staff had started new MAR charts but also completed the old ones, and not because Mr F had received the medication twice. The MAR charts kept a running record of the number of tablets remaining and the Care Provider said it had checked these balances to provide assurances Mr F had received the correct amount of medication. The Care Provider apologised for the confusion and said staff had been reminded of the importance of completing and checking documentation; and
• Mr F’s urine output was not always correctly recorded because staff used the wrong form.

Council safeguarding investigation

29. Also in July 2020, the Council investigated some of the issues raised by Mr X under its safeguarding procedures. These were:
• the development of pressure sores;
• poor catheter care and personal care;
• a deterioration in mobility; and
• weight loss.
30. New or different findings from the Care Provider which were made by the safeguarding investigation were as follows:
• the evidence demonstrated the Care Home had treated Mr F’s pressure sore appropriately. However, there were some inconsistencies in the Care Home’s recordings. In addition, the nurses who took over treatment of Mr F stated his discharge summary was insufficiently detailed although they did not raise any concerns about the care itself. The investigator said action points had come out of this which the Council would follow up;
• Mr F was discharged to the Care Home with a three-way catheter which would normally be changed by the hospital to a two-way catheter before discharge. The investigation stated the three-way catheter had been inserted on medical advice. It was changed at the end of March and so did not require its monthly change whilst Mr F was at the Care Home. The district nurses did not raise any issues to the investigator when they took over Mr F’s care;
• Mr F’s daily notes recorded he received personal care almost daily with him refusing care on only four occasions. He was unable to have a shower because COVID-19 meant communal areas were not in use. External visitors such as chiropodists were also unable to visit;
• there was no evidence Mr F was able to mobilise whilst he was in hospital or while he was at the Care Home; and
• there was no evidence Mr F lost weight whilst at the Care Home because he was not weighed on discharge home. He had capacity to choose what food he wanted to eat and the daily notes recorded he ate or drank milk each day. When his health began to deteriorate, he began to refuse meals. The Care Home contacted the GP twice about this and so took appropriate action.

Response by the Council

31. Mr X then complained to the Council. The Council responded to Mr X’s complaint, explaining it had sought medical advice where the complaints included health matters.
32. Where the Council’s view was in line with the Care Provider’s or the safeguarding investigation’s conclusions, I have not repeated those comments here. New or different findings made by the Council were as follows:
• there was no definitive evidence Mr F caught COVID-19 in the Care Home, but this could not be ruled out. At the time Mr F was a resident, there was not the testing or personal protective equipment (PPE) available that there was later. Patients were discharged from hospital without tests. There was no evidence of poor practice by the Care Home which led to Mr F contracting COVID-19; and
• although Mr F was flagged by the hospital as being at risk from malnutrition, there was insufficient recording by the Care Home about the implications of this. The Care Home failed to set up a food chart. The daily care notes showed Mr F began to eat less and towards the end of his stay, ate almost nothing. There was no recording of what steps the Care Home took to address the issue. In addition, the Care Home failed to weigh Mr X on discharge which would have been useful. However, Mr F was generally frail and the hospital had indicated Mr F should only be given food and fluids as requested and low intake was likely. The Council therefore concluded there was no evidence the faults it had identified had caused Mr F harm.
33. Mr X remained unhappy and complained to the Ombudsman.

My findings

34. I examined the documentation Mr X and the Council sent me. In each instance, I checked the complaint responses from the Council and the Care Provider against the records. I have also checked the safeguarding documentation completed by the Council. In addition, I considered the COVID-19 procedures and government guidance in place at that time.

Placement in a dementia unit, manager not clinically trained and COVID-19 precautions (complaints in paragraph 1a), 1c) and 1d))

35. My findings are in line with those of the Council and Care Home’s. There was no fault in the Care Home’s actions.

Rehabilitation for Mr F and admission to a care home requiring improvement (complaint 1b, 1c and 2)

36. Under the COVID-19 guidance at the time, medically fit patients were being discharged from hospitals under emergency procedures to any available care home placement. This included care homes deemed by CQC as requiring improvement. All care homes were entering lockdown and were not allowing entrance to non-essential staff. On balance, it is unlikely that Mr F would have received physiotherapy from external staff at any care home he was discharged to. Furthermore, the Care Home assessed him on admittance as requiring nursing in bed, and other than some instances of him being hoisted into his chair, this prognosis did not change. There is no indication Mr F challenged that stance. There was no fault in the Care Home’s actions.

Accuracy of record-keeping (complaint 1e))

37. To summarise, the three previous investigations found the following areas of fault with the Care Home’s record-keeping:
• Mr F’s allergies were not recorded on his care plan;
• some of the medication administration records were misleading;
• urine output had not been properly recorded;
• there were inconsistencies in the recording of the management of Mr F’s pressure sore and a lack of detail in the discharge notes to the district nurses; and
• there was a failure to record what Mr F ate.
38. In addition to the faults identified above, Mr F’s discharge sheet said his oxygen should increase from 1L a minute to 4L when he mobilised. This was not recorded on Mr F’s care plan. This is also fault and, as with the faults in paragraph 37, a breach of the CQC Regulation 17.
39. However, these faults did not cause Mr F an injustice for the following reasons:
• the failure to record Mr F’s adverse reactions to some medications did not lead to any problems for him;
• his pressure sore was shown to have significantly improved by the time he left the Care Home;
• the Care Provider explained Mr F received the correct medication and explained how this was checked; and
• towards the end of Mr F’s stay at the Care Home, he was approaching end of life and his appetite was diminishing. He had capacity to choose whether to eat or not. So even if the records had showed weight loss due to refusal to eat, we could not say this was as a direct result of any action, or lack of action, by the Care Home.
40. Although these faults in record keeping did not cause Mr F an injustice, they have the potential, if repeated, to cause injustice to others in future. I have therefore recommended a service improvement.
41. In relation to other record keeping, the records were sufficiently detailed to demonstrate Mr F was given, or offered, the personal care he needed. There was no fault in the Care Home’s actions.

Response to buzzer, failure to inform family when Mr F became ill, obtaining Mr F’s sister’s phone number and call to 111 (complaints 1f, g, h and i)

42. Mr X reported one incident when he said the Care Home delayed in answering Mr F’s buzzer whilst Mr F was on the phone to his sister.
43. I will not investigate this matter further. There is not enough evidence of fault to justify investigating and there is no evidence Mr F was caused an injustice by what may have happened.
44. In relation to the other three issues, the Care Provider has provided a response to address Mr X’s concerns. This response is robust and supported by evidence. I do not propose to investigate these matters further because it is unlikely I would find fault and in any case, they did not cause Mr F any significant injustice.

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Agreed action

45. Within three months of the date of the final decision, the Council has agreed to ensure the Care Provider reminds staff at the Care Home of the importance of thorough and accurate record keeping, with particular reference to ensuring any instructions on the hospital discharge sheet are transferred accurately to the resident’s care plan.

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Final decision

46. The Care Provider and Council have already admitted there were areas of fault in the way it kept some of Mr F’s records. However, this did not cause any significant injustice to Mr F. The Council has agreed to my recommendation. I have completed my investigation.

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Parts of the complaint that I did not investigate

47. I have not investigated the complaint in paragraph 1j. That is because the Information Commissioner’s Office is better placed to investigate complaints that the Care Provider refused initially to provide Mr X with Mr F’s health and care records.

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Investigator's decision on behalf of the Ombudsman