Summary: The Care Provider did not adequately record Mr D’s fluid intake or involve Mrs C when compiling key documents. This has caused Mrs C uncertainty about whether, but for the faults identified, Mr D’s health would not have declined. The Care Provider has already taken steps to address the failures identified. It has also agreed to apologise to Mrs C for the uncertainty and distress caused by these failures and make procedural changes.

The complaint

1. The complainant, whom I refer to as Mrs C, complains about services provided to her late father, whom I refer to as Mr D. Mrs C complains there was service failure by the Care Provider which resulted in Mr D becoming dehydrated and needing hospice care.
2. Mrs C also complains the Care Provider failed to: -
1. appropriately care plan, review, and monitor, Mr D’s care;
2. provide enough information about Mr D’s well-being; and
3. ensure that carers could provide appropriate support.

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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. 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)
6. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

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How I considered this complaint

7. I read documents provided by Mrs C and spoke with her sister, with her consent. Based on this information I made enquiries and spoke with the Care Provider. I considered the Care Provider’s response.
8. I have written to Mrs C and the Care Provider with my draft decision and given them an opportunity to comment.

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What I found

What should have happened

9. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. I have used the Care Quality Commission (Registration) Regulations 2009 when considering this complaint. I have referred to these as the “Regulations”.
10. Regulation 14 says care providers must meet service user’s nutritional and hydration needs. The associated guidance says care providers:-
• “must include people's nutrition and hydration needs when they make an initial assessment of their care, treatment and support needs and in the ongoing review of these. The assessment and review should include risks related to people's nutritional and hydration needs.
• Providers should have a food and drink strategy that addresses the nutritional needs of people using the service.”
11. It goes on to say, “Nutrition and hydration assessments must be carried out by people with the required skills and knowledge. The assessments should follow nationally recognised guidance and identify, as a minimum:
• requirements to sustain life, support the agreed care and treatment, and support ongoing good health……
• how to support people's good health including the level of support needed, timing of meals, and the provision of appropriate and enough quantities of food and drink……
• snacks or other food should be available between meals for those who prefer to eat 'little and often'.”
12. Regulation 9 “Person Centred Care” says care providers should enable and support relevant people to make or participate in making, decisions relating to the service user's care or treatment to the maximum extent possible…”.

What happened

Background information

13. From May 2018 Mr D received support from a care agency. The Care Provider took over the care agency on 1 January 2019 and became responsible for Mr D’s care.
14. On 16 January, due to an increase in Mr D’s care needs the Care Provider introduced a live-in carer. The Care Provider says that usually it provides live-in carers on a rotational two-week basis. Each live-in carer is entitled to a daily two hour break at the service user’s convenience.
15. The Care Provider says because Mr D needed end of life care, and the family’s concern about a change in carer, the initial live-in carer was booked for four weeks.
16. On 21 January the manager visited Mr D and checked the daily records, and food and fluid charts. The manager says that she told the live-in carer to provide more detailed accounts of what he was doing and documenting his actions even if Mr D declined care.
17. On 23 January Mr D met the criteria for NHS Continuing Health Care. This meant that he was entitled to an additional three free calls per day. The Care Provider did not have a contract with the NHS but decided to provide the additional care at no extra cost. This was so Mr D could have his previous carers who he was familiar with.

Communication

18. Mrs C says she was not properly updated on her father’s care as the live-in carer did not provide detailed information about her father. She also says the live-in carer inappropriately contacted her on 8 February instead of calling the on call support.
19. The Care Provider says the family asked the live-in carer to keep them updated and tell them as soon as there were any concerns about Mr D. It says family members contacted the manager directly about concerns. There are emails that show the Care Provider was in regular contact with Mrs C and her sister.
20. On 8 February Mr D became confused and distressed and the live-in carer was finding it difficult to manage. The live-in carer called Mrs C in the early hours of the morning. She told him to call the Health Care Lead. The live-in carer did this and obtained extra support. The Care Provider says that it is usual policy for care staff to call the out of hours team for support. In this instance however the live-in carer acted in line with the family’s wishes, contacting them first.

Was there fault causing injustice?

21. I am unable to say Mrs C did not know who to contact if she had concerns. There is an email trail that shows Mrs C knew who to speak to about any problems. Mrs C also had daily contact with the live-in carer about Mr D’s wellbeing.
22. I do not know what was included in conversations between the live-in carer and Mrs C about communication, it is therefore difficult to say the live-in carer should not have contacted Mrs C in the early hours of 8 February. There is a dispute about whether the live-in carer knew about the on call service. There is insufficient evidence for me to decide if this was the case or whether the live-in carer was following the family’s wishes in contacting them first.
23. The Care Provider has accepted the live-in carer should not have used What’s App as a means of communication with the family. It has apologised to the family for this. In future it will tell families about the on-call service and communication process at the start of the service to avoid any confusion. I consider these actions are sufficient to remedy any shortfalls in this element of the complaint.

Food and fluid intake

24. Mrs C says the Care Provider failed to monitor Mr D’s food and fluid intake. She says when the hospice admitted Mr D he was dehydrated.
25. Mr D’s care plan says that staff should “encourage little and often food and fluids and complete the food and fluid charts in situ”.
26. The daily records show that main meals such as breakfast, lunch and dinner were offered. There is also evidence of carers offering and providing drinks. In addition, the Care Provider completed fluid balance charts. During the period 15 January to 8 February the records show that Mr D had between 650 and 350ml of drink per day. During this period there are two days when the Care Provider recorded fluid output.
27. The Care Provider says it could have made more detailed notes about Mr D’s fluid and food intake. However, it says there was regular district nurse intervention and she/he raised no concerns about Mr D’s hydration, nor did they contact the GP or escalate the matter.

Was there fault causing injustice?

28. I do not consider the Care Provider properly assessed Mr D’s need for fluid in line with Regulation 14. Although carers documented fluid intake there is no assessment to say: -
• how much fluid Mr D should be drinking daily;
• how much fluid output Mr D had daily;
• what action carers should take if Mr D did not reach the assessed targets.
29. There is a lack of evidence of the Care Provider complying with the care plan in supporting Mr D to have food and drink little and often, or of staff encouraging Mr D to drink prescribed fortisep drinks.
30. It is difficult to say for certain what effect, if any, the failures had on Mr D. This is because district nurses visited Mr D regularly. They visited daily in the three days leading up to Mr D’s admission into a hospice. I consider the district nurses would have intervened if they considered Mr D was not drinking enough or was suffering with dehydration. Mr D was clearly in the terminal stages of his life and his health was declining. I am therefore unable to say for certain the failures I have identified caused Mr D any ill effect.
31. Mrs C does however have uncertainty about whether the Care Provider could have taken any other action to increase Mr D’s food and fluid intake.

Failure to provide and involve family with key documents

32. Mrs C says the Care Provider failed to involve family when key documents such as a contract and care plan were signed. Mrs C says the Care Provider was aware the family were involved and liaised with them regularly. She says that on this basis the Care Provider should have involved the family when it discussed these documents with Mr D.

Was there fault causing injustice?

33. While the Care Provider did update the family about Mr D’s care, I consider it should have involved or told the family about the care plan and the contract in line with Regulation 9. These are important documents and involving the family would have allowed them the opportunity to comment on the care.
34. I cannot say now whether there would have been a difference had the Care Provider given more information to Mrs C. Mrs C however had time and trouble in pursuing a care plan. She also lost an opportunity to contribute to the care plan.
35. The Care Provider has accepted that it should have provided more detailed information at the start of the service and consulted with the family along the way. It has apologised for these short comings.

Failure to provide acceptable personal and domestic

36. Mrs C complains carers did not provide enough domestic care and that Mr D’s property was left dirty. The Care Provider disputes this and says it did not have an opportunity to clean the property in the final days Mr D was at home as the family did not want Mr D disturbed.
37. There is no record within the care plan about what domestic tasks carers should provide Mr D. There are also limited records of carers providing domestic care tasks for Mr D.
38. Mrs C says hospice staff raised concerns that Mr D’s socks were not changed, and his feet were unwashed.

Was there fault causing injustice?

39. The lack of recording about what domestic care tasks carers completed casts doubt about what domestic care the carers completed. Mrs C therefore has uncertainty about what tasks and the level of cleaning carers provided.
40. There is clear daily recording that carers provided Mr D with personal care tasks. Some records are more detailed than others, but I cannot say that carers did not support Mr D with his personal care.
41. Neither family nor other professionals involved at the time raised any concerns about Mr D’s personal care. I am therefore unable to find fault with the Care Provider on this aspect of the complaint.

Failure to provide an adequate live-in carer

42. Mrs C complains the live-in carer was exhausted. Mrs C says that this may have affected his decision making especially on 8 February. Mrs C also says the live-in carer was not appropriately qualified to care for her father.
43. The Care Provider made an exception in allowing the live-in carer to stay four weeks rather than two so Mr D could have continuity of care. It will no longer make any exceptions.

Was there fault causing injustice?

44. Whether the live-in carer had the correct breaks, within the day, or rotationally is an employee matter that I am unable to look at.
45. For the reasons set out at paragraph 22 I also cannot say the live-in carer’s actions on 8 February were affected by tiredness or lack of knowledge.
46. From the care records it does appear, especially in the latter stages, the live-in carer was providing care both during the day and night. However, health staff who visited regularly did not raise any concerns about the live-in carer’s abilities. In addition, the Care Provider organised additional staff to support the live-in carer with Mr D’s increased needs and to support with the use of equipment. Mrs C herself only appears to have raised concerns about the live-in carer on 9 February, the point at which Mr D was admitted to a hospice. I am therefore unable to say the live-in carer did not have the required skills or abilities for the job.

Agreed action

47. The Care Provider has already taken several steps in response to this complaint. It has apologised for not providing detailed information about the services it was providing and including the family as much as it should have done. It has reminded care staff about the importance of making detailed care records. It has also recruited a Clinical and Quality Assurance Director who will ensure care plans are accurate and effective and include risk assessments and escalation plans.
48. In addition to the steps the Care Provider has already taken, it has agreed to: -
1. make a further apology for the failures that I have identified in this statement and the effect that it has had on Mrs C;
2. remind staff of the importance of involving relevant people when compiling documents;
3. review training about what carers should do about food and fluid intake monitoring in light of this statement.
49. The Care Provider should complete task (a) within one month of the final decision, and (b) to (c) within three months of the final decision.

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Final decision

50. I have found service failure in the actions of the Care Provider which has caused injustice. I have closed the complaint based on the agreed action above.
51. As I have found fault in the actions of the Care Provider and under the information sharing agreement between the Local Government and Social Care Ombudsman and CQC, I will also share this decision with CQC.

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Investigator's decision on behalf of the Ombudsman