Summary: The Care Provider failed to properly record services it provided and involve family when the service user’s health declined. As a result, Mrs C lost an opportunity to provide extra help to her mother and potentially see her before she died. The Care Provider has agreed to apologise to Mrs C and make procedural changes. It will also pay Mrs C £500 to reflect the uncertainty caused by these failures, and her time and trouble in making her complaint.

The complaint

1. The complainant, whom I refer to as Mrs C, complains the Care Provider failed to escalate concerns and provide appropriate care to her mother, who I have referred to as Mrs D. Mrs C says this resulted in a deterioration in her mother’s health. Mrs C also complains the Care Provider failed to deal with her complaint properly.

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The Ombudsman’s role and powers

2. 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)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. 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

5. I spoke with Mrs C and considered written information she provided. I asked the Care Provider questions and considered its response. I have written to Mrs C and the Care Provider with my draft decision and given them an opportunity to comment.

6. I based my decision on the relevant legislation, government guidance and the Care Provider’s own policies which are detailed below.

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What I found

What should have happened

7. 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”.
8. 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…”.
9. Regulation 12 “Safe care and treatment” says care providers must assess risks to people's health and safety during any care and make sure that staff have the qualifications, competence, skills and experience to keep people safe.”
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. Regulation 17, says care providers should “maintain securely” records and should have “an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided”.
12. The Care Provider’s complaints procedure says once it has a treated a concern as a complaint it must send out an acknowledgement within five days and must address the complaint within 28 days. If the Care Provider needs longer than 28 days, it must update the complainant and apologise for the delay.

Background information

13. Mrs D lived at home and received three calls a day from the Care Provider which she paid for privately. Mrs C made no complaints about her mother’s care until July 2018. Mrs C says the Care Provider failed to tell her about a deterioration in her mother’s health and abilities during July and that her mother died at home on 20 July without her knowing the seriousness of her condition. Mrs C says she and her brother live a distance from Mrs D, they therefore relied on the Care Provider to update them on Mrs D’s well-being and in particular: -

• deterioration in Mrs C’s health and mobility;
• refusal to take nutrition, hydration and medication;
• information on when medical advice was sought and the outcome of these requests.

14. Mrs C says the Care Provider was aware to contact her or her brother of any concerns. Mrs C says she would have taken action and insisted on medical help if she or her brother had known that Mrs D had become bed bound. Mrs C also believes she could have provided extra support to her mother if she had known of her difficulties. In addition, Mrs C says Mrs D had pulmonary thrombosis and this was a result of care staff not helping Mrs D to mobilise. Mrs C feels that as a result of the Care Provider’s failings she lost the opportunity to visit her mother before she died.

What happened

15. I have reviewed the Care Provider’s records between 2 July to 18 July. Records on 2 July show that when contacted by Mrs D’s son, carers told him that Mrs D’s mobility had deteriorated and that she would benefit from a bed lever. From then until her death the care notes show a decline in Mrs D’s health and abilities. The records show that on more than one occasion Mrs D refused to take medication, have food, and on 10 July record Mrs D was no longer able to weight bear.
16. Carers raised concerns about Mrs D’s health with office staff on 3,4,5 and 10 July and with a family member on 2 July. On 4 July carers contacted the GP on the advice of the emergency helpline,111, but the Care Provider cannot produce any other details of actions taken. Mrs C says she was unaware that the carers had called 111 on that day.
17. The Care Provider says there is a lack of recording as flooding destroyed paper records that it kept in storage. There is therefore no care plan or assessment about the services the Care Provider should have provided Mrs D, or agreed communication methods with family.
18. In November 2018 Mrs C says she asked the Care Provider for information about what action the Care Provider took when carers raised concerns or asked for advice. Mrs C also asked for evidence of what the Care Provider advised care staff to do.
19. A month later Mrs C had not received a response and complained. She lodged a formal complaint on 20 December 2018. The Care Provider failed to respond to this email and until Mrs C sent a further email on 1 February 2019. The Care Provider responded on 13 February but did not provide a complete response until 3 June after further prompting from Mrs C.

Was there fault causing injustice?

Care Records

20. Regulation 17 says care providers should store records “securely”. It is unfortunate that records were lost due to flooding. I am unable to say however that the Care Provider was at fault for this loss. The flooding was out of its control and not because of fault by the Care Provider.
21. However, the daily records which were kept at Mrs D’s property and unaffected by flooding are inadequate and a potential breach of Regulation 17. The records fail to say what actions care staff took about Mrs D’s care and health, lack of nutrition and medication and follow up actions after Care Provider conversations with the GP.
22. As a result of these faults Mrs C does not know what care Mrs D received in the last few days of her life. She is left with uncertainty about whether the Care Provider acted properly.

Communication with Mrs C

23. The Care Provider did speak to Mrs C’s brother on 2 July and 16 July 2018, it is unclear whether Mrs C knew about these calls. The second conversation concerned the purchase of straws to help with Mrs D’s hydration. The family would therefore have had knowledge that there were issues with Mrs D’s hydration.
24. However, after this date Mrs D’s condition continued to deteriorate. I consider the Care Provider was at fault for failing to contact Mrs C about a deterioration in Mrs D’s abilities and health. Carers recorded Mrs D’s inability to weight bear and refusal, at times, to take medication or eat. They have also recorded times when they sought medical attention including calling 111 and escalated their concerns to office staff. The Care Provider did not however contact Mrs C about these concerns, so she was unaware of the decline in Mrs D’s health.
25. Regulation 9 highlights the importance of involving family members in decision making and keeping them involved. The evidence shows the Care Provider failed to do this.
26. Due to the distance Mrs C lived from her mother she was reliant on the Care Provider to update her on Mrs D’s condition. Mrs C has lost an opportunity to be involved in her mother’s care and potentially provide additional support. Mrs C also has the uncertainty of not knowing if, but for the faults identified, she could have provided additional support and indeed seen her mother before she died.

Complaint handling

27. The Care Provider is at fault for not dealing with Mrs C’s complaint properly. It failed to acknowledge Mrs C’s concerns as a complaint and did not respond to the complaint within 28 days. Mrs C was put to the time and effort of contacting the Care Provider on several occasions to find out what was happening with her complaint.
28. The Care Provider has explained the delay in dealing with the complaint was because of the lack of records and involved staff members leaving. It has apologised for the delay.
29. While I welcome the Care Provider’s apology and understand the difficulties it was under, I do not consider it adequately reflects Mrs C’s time and trouble in pursuing her complaint.

Failure to provide appropriate care

30. Mrs C says Mrs D died of pulmonary thrombosis. Mrs C says this was caused by a failure of carers to mobilise her mother.
31. The records available show Mrs D’s mobility deteriorated, there is however no risk assessment or review of her mobility needs. I do not consider the Care Provider completed these documents or acted in accordance with Regulation 12. Mrs C has the uncertainty of not knowing whether the Care Provider did as much as it could to support Mrs D with her mobility. But I cannot evidence the Care Provider’s actions caused or contributed to Mrs D’s pulmonary thrombosis.
32. Records also show Mrs D’s appetite decreased and the amount she ate and drank reduced. There is no note or reference of care staff assessing whether Mrs D was eating or drinking enough or monitoring her dietary intake. Therefore, on balance, I think it more likely than not that the Care Provider did not complete these assessments and failed to meet Mrs D’s nutrition and hydration needs in line with Regulation 14.
33. Mrs C has the uncertainty of not knowing whether had the Care Provider completed the correct assessments Mrs D's fluid and nutrition could have been improved.

Agreed action

34. I consider the Care Provider’s actions have caused Mrs C injustice. The Care Provider has agreed to take the following actions to remedy the complaint: -
1. apologise to Mrs C for the failures I have identified within this statement and the uncertainty and anxiety these have caused her;
2. make a payment of £500 for the uncertainty and distress caused by the failures I have identified, and the time and trouble Mrs C has had in pursuing this complaint;
3. remind care staff about the importance of properly recording actions taken and advice sought;
4. remind staff about the importance of risk assessing and action planning when there is a deterioration in a person’s abilities whether this be with their mobility or food and nutrition;
5. review procedures to ensure as far as possible workers follow the complaints procedure and its time scales;
6. remind staff about the importance of involving relevant family members about substantial changes in service users’ care needs, when care staff call health services.
35. The Care Provider should complete (a) and (b) within a month of the final decision and (c)-(f) within three months of the final decision.

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Final decision

36. I have found service failure by the Care Provider which has caused injustice. I have completed my investigation and closed the complaint based on the agreed remedy.
37. As there is a potential breach of the regulatory standards 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