Top Care Homes Limited (18 007 387)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 11 Apr 2019

The Ombudsman's final decision:

Summary: Mrs X, complained on behalf of her husband Mr X, about the standard of care he received from the care home. The Ombudsman has found evidence of fault with some aspects of service provision. To remedy the injustice caused, the Home has agreed to refund the placement cost, apologise to Mr and Mrs X and review its procedures.

The complaint

  1. Mrs X has complained on behalf of her husband Mr X. Mrs X was unhappy with the standard of care received by Mr X during a period of respite care at a residential care home (“the Home”) owned and managed by Top Care Homes Limited. She says this poor care led to a deterioration in his health and an emergency admission to hospital.
  2. Mrs X says this has caused both her and her husband great distress and inconvenience.

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The Ombudsman’s role and powers

  1. We investigate complaints about adult social care providers. If there has been fault, we consider whether it has caused an injustice and, if it has, we may suggest a remedy. (Local Government Act 1974, sections 34H(3) and (4), as amended)
  2. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

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How I considered this complaint

  1. I have considered all the information provided by Mrs X and the Home including its response to my enquiries.
  2. I have discussed the complaint with Mrs X on the telephone.
  3. A draft version of this decision was sent to Mrs X and the Home for comment. I have considered the comments received before reaching my final decision.

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What I found

  1. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) We consider the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
  2. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
  3. Regulation 14 of the 2014 Regulations says the nutrition and hydration needs of residents must be met. They must receive suitable nutritious food and fluid to sustain life and good health, with support to eat and drink if needed.
  4. Regulation 17 of the 2014 Regulations requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.

The Home’s Conditions of Admission and Terms of Business

  1. This states the following:
  2. “In the event that a resident vacates a room permanently, for whatever reason, we reserve the right to make a vacant room charge, not exceeding one week’s fee where notice has not or cannot be given. In the event of the room being vacated temporarily the fees will be payable for the retention of the room.”

The Home’s Accident Procedure (applicable at the time)

  1. This states the following:
  2. “In all cases of either minor or major accidents sustained whilst in the home, the details of the same are logged with as much detail as possible into the accident book and within the shortest possible time and the senior person on duty informed”.
  3. “Minor accidents to either staff or residents may be corrected by immediate action by staff”.
  4. “Any major accidents. Fractures, head injuries, bleeding etc must be reported to relatives, GP and CSCI this will be done by the manager or deputy”.

What happened

  1. In May 2017, Mr X went to stay in the Home for a period of two weeks. This was to enable Mrs X, who was his main carer, to go abroad for a much needed break. She says she chose the Home because it was both local and able to manage her husband’s catheter.
  2. Mrs X paid the Home for the total cost of the stay upon admission. I have not been provided with a signed contract about this but I have seen the Home’s standards terms and conditions with the relevant paragraph to this complaint set out at paragraph 12 above.
  3. Before he went into the Home, Mrs X provided the manager with clear instructions about Mr X’s daily routine, including incontinence care and arrangements for when Mr X wanted to leave the home. Some of this information was delivered verbally. She also provided a written summary. Mrs X asked for an assessment to be carried out prior to Mr X going into the Home but she was told this was not possible.
  4. Mrs X gave the following instructions to the Home:
  • Mrs X told the Home Mr X could go out as long as he informed staff when he was leaving and when he would return. Staff should also have his mobile number. He should not go out if it was warm.
  • He should use a night bag a stand to manage his night time incontinence. This was because his day time leg bag would not hold enough fluid and there was a risk of infection if this was used at night and was not emptied often enough.
  • He should drink plenty of fluids, including decaffeinated hot drinks to reduce the risk of a urinary tract infection (UTI).
  1. After Mrs X had left to go on holiday, the Home carried out its own assessment of Mr X and produced its own care plan. According to the Home, Mrs X’s instructions were attached to this. There is a dispute about when the assessment was carried out because it is dated two days after arrival.
  2. Mr X appeared to settle well at first. However, according to Mrs X his health and behaviour started to change on the second day.

Day two

  1. Mrs X received a call from Mr X, who was in a distressed state, at around 6am complaining that his leg bag was full. Mrs X was concerned that his usual night bag and stand, which Mr X was used to and could hold more fluid was not being used. Mrs X says she tried unsuccessfully to contact a member of staff at the home to discuss this. She phoned numerous times but the call went straight to answerphone.

Day three

  1. The Home recorded that Mr X was confused about where he was in the morning. He was looking for his wife but could not find her.

Day four

  1. Mr X collapsed at the top of the stairs and lost consciousness for a short while. Neither his family nor GP were notified. While the incident was recorded in the daily logs, a separate accident form was not completed. Mr X was advised by staff that it was best if he did not go out of the home that afternoon. While he agreed to stay in during the afternoon he went out for tea with his granddaughter. Upon his return, he appeared confused. His granddaughter reported she was concerned about her grandfather. The Home recorded that they would call the doctor the next day due to a suspected UTI.

Day five

  1. Mr X had a fall at the Home which was reported to his daughter. An accident report form was completed. In response to the concerns from the previous day, the doctor visited who prescribed antibiotics for a suspected UTI.

Day six

  1. Mr X left the home early in the morning before breakfast. He was brought back to the home by a neighbour a couple of hours later. Mr X had complained to the neighbour about his catheter bag being full and being in pain.
  2. Mr X left of his own accord via the fire exit a couple of hours later. He was found later that afternoon by a neighbour slumped and unresponsive in his conservatory. The neighbour called for an ambulance. Mr X was admitted to hospital with a UTI. He did not return to the Home. Mrs X requested a refund for the time Mr X was no longer at the Home. The Home refused.

Mrs X’s complaint

  1. Mrs X says his hospital admission was as a direct result of poor care and the Home not following her instructions as set out verbally and in her own care plan.
  2. In particular she complained about:
  • The purpose of the respite care (to give her a break from her caring role) was defeated because Mr X kept ringing her in a distressed state.
  • The fact Mr X’s short-term memory problems were not acknowledged by the Home.
  • The Home’s assessment and resultant care plan was flawed because no one other than Mr X was present. She says this was done on day three rather than prior to admission as she had requested. She also says the fact Mr X was recorded as not having hearing problems calls into doubt the accuracy of the assessment because Mr X was wearing his hearing aids on the date of admission. However, on the care plan there is no reference to these. She says if the assessment was carried out without him wearing his hearing aid then this would impact on his ability to provide accurate information.
  • No one was contacted about the fall on day three despite Mr X having a heart condition (for which he was on medication) and low blood pressure.
  • His continence care was not properly administered. He complained about it being full on a number of occasions and the night bag was not used contrary to her instructions.
  • He was not properly hydrated – the hospital said his urine was cloudy upon admission in addition to him having a UTI with sepsis.
  • He was not prevented from going out despite being told. The home did not have his mobile number which added to the confusion when he left the home on day six.
  • It was the decision of the Home not to let Mr X return. They said they were unable to provide the care he needed.
  1. She says Mr X is entitled to a refund for the period of time he was in hospital. She had to pay for a second care home to look after Mr X once he was discharged from hospital.

The Home’s response

  1. The Home says it did not refuse to have Mr X return to its care, rather the family chose to move him to a different home. It said it would need to assess him while in hospital to ensure it could still meet his needs but this was standard practice when a resident was admitted to hospital. The family decided to move Mr X to a different home before this assessment could take place.
  2. The Home’s complaint response made the following points:
  • It is standard practice for the “pre-admission checklist” to be completed on the day of arrival rather than in advance.
  • There are no signed contracts for respite care.
  • It can be difficult to ascertain difference between possible UTI symptoms and disorientation arising from being in a new and unfamiliar environment.
  • In the absence of Mr X lacking a capacity and there being a Deprivation of Liberty Safeguard (“DoLS”) in place, the Home had no legal authority to either stop Mr X going out or impose conditions on his leaving.
  • It is standard practice for the Home to assess residents in hospital before readmission.
  • Mr X had capacity to make his own decisions. There was nothing in Mrs X’s care plan to indicate there were any issues with his short-term memory.
  • Mr X’s fluids were monitored daily.
  • The information provided by Mrs X about catheter care was basic. There was no evidence that care staff did not refer to Mrs X’s care plan.
  • There was no evidence to support Mrs X’s assertion that poor care caused Mr X’s hospital admission. His deterioration could have been a pre-existing condition, confusion/disorientation or possible separation anxiety. This was a possibility because Mrs X said Mr X kept calling her mobile.
  • The Home would not offer a refund while the room was unavailable to be used by another person, as was the case here. This was in line with its standard contractual terms and conditions.
  • As a goodwill gesture home offered to make a charitable donation in Mr X’s name.
  1. My investigation has focussed on the events that took place during Mr X’s stay at the Home and what happened immediately afterwards. I have noted from reading the records there were some difficult exchanges between Mrs X and the Home in respect of her complaint. I have not dealt with this during my investigation as this is not directly relevant to the substantive issues raised about poor care.

Analysis

  1. Mrs X had made a number of allegations against the Home. I will deal with each of these in turn.

Inadequate care plan

  1. In response to Mrs X’s initial complaint, the Home said the following statement to Mrs X,

“I respect your opinion that the care assessment and step down care plan may not have adequately identified Mr X's care needs but I feel that this is in part due to the fact the care plan you provided did not have adequate or detailed information”.

  1. In my view this is an acknowledgement that the care plan produced by the Home was inadequate. I agree. The care plan fell short of the detail I would expect to see in such a document. There is no detail about the main concern for Mrs X which was his catheter care. The only references were “Catheter in situ” and at night, “gets up to use the toilet”.
  2. The assessment document (dated two days after admission) states “Mr X is aware of when this requires emptying or changing. Requires assistance of one carer”. The section headed “Please state exact current management of continence including products used and input from continence advisor”. All that was put here is “Catheter bag. D/N in place.”
  3. Mrs X has disputed this entry. She says Mr X’s short term memory means he does not always know when his bag needs to be changed.
  4. The onus is on the Home to produce a care plan that is fit for purpose. This is clear in the Regulation 9 summarised out at paragraph 8 above. Mrs X asked for the assessment to take place before admission so she could participate but the Home said this was not possible due to staff shortages. Instead the Home said it was usual practice for assessments to take place on the day of arrival. This may be appropriate in some cases.
  5. But in this situation, it was not. I have concluded that this lack of direct information sharing between Mrs X and the Home had a direct impact on what happened afterwards. The Home cannot have it both ways. It cannot say it was acceptable to assess Mr X on arrival but then fail to carry out its own detailed assessment with enough information to ensure all carers would know what catheter care to offer Mr X.
  6. The Home’s complaint response is critical of Mrs X’s care plan. But in actual fact it is far more detailed than that of the Home.
  7. The care plan produced by the home did not meet the required standards and is fault.

Delay in carrying out assessments

  1. Mrs X has expressed her concern about when certain assessments were carried out. The main “pre-admission” assessment is dated as if it took place on day three.
  2. The Home has said this was dated incorrectly but did take place on the day of admission. Mrs X has questioned this because the manager had written “no glasses or hearing aid”. However, Mr X is hard of hearing and wore a hearing aid in both ears and Mrs X confirmed he was wearing them when she left him at the Home on the first day. She says if Mr X had been assessed on that day then the manager would have seen for herself he wore hearing aids.
  3. Mrs X also says, putting aside the date of the assessment, its efficacy was flawed because, if Mr X was not wearing his hearing aids this would have significantly affected his ability to understand the questions that were being asked of him. It also reinforces her argument that the assessment should have been carried out in the presence of a family member so they could have provided additional information.
  4. Other documents are also dated on day three, namely the risk assessment dealing with when Mr X left the premises and the associated mental capacity assessment. To manage the risk the Home said it should be aware when he was going out, where he was going and what he was wearing.
  5. I note the two other risk assessments (falls and manual handling) were both dated on the day of admission.
  6. The manager who completed these forms is no longer employed by the Home so it has not been possible to interview her about this. While I accept it is possible that the documents were incorrectly dated, the fact this happened on three separate documents, (two hand written and one typed), together with the discrepancy about the hearing aid had led me to conclude, on balance of probabilities that the assessments were not completed on the day of admission. This is fault.

Poor catheter care led to Mr X’s UTI

  1. The fault in the care plan inevitably casts doubt over the quality of the catheter care that was provided to Mr X. Mrs X says the failure by the Home to ensure the catheter bag was emptied frequently enough and drink enough caused the UTI that led to his hospital admission. This is a serious allegation. In order for me to form a view on this I must look at all of the available records. In addition to the daily care logs, the Home kept fluid and balance charts which record the times/quantities of fluid intake and output.
  2. One of the main concerns expressed by Mrs X was the Home’s failure to use the night stand in accordance with her instructions. This held a large two litre bag. The reason Mr X used the larger night bag was to avoid the risk of it overfilling during the night if it was not emptied frequently enough.
  3. The Home did not use this for health and safety reasons. There were concerns he could trip over the stand when in an unfamiliar environment. While I am unable to question the decision itself as it was a professional judgement by the manager, I would have expected to see this recorded in the care plan and arguably communicated to Mrs X as it was contrary to her expressed preferences made on behalf of Mr X.
  4. The records do not provide a consistent record of when the bag was emptied and how much fluid was passed. There are three occasions on which Mr X was either seeking assistance with his bag or was complaining about it being full.
  5. I accept there may have been occasions when Mr X emptied his own bag which may have accounted for it not being recorded. There were also times that Mr X was not on the premises that could account for the absence of some records.
  6. While the records are inconsistent I do not have sufficient evidence to find that the Home failed to provide adequate catheter care or this was the cause of Mr X’s UTI. As the Home has said, it is possible Mr X already had an infection in his system. He was also away from the home for most of the sixth day when his condition deteriorated. I will consider this aspect of the complaint later in this decision.

Fluid intake

  1. Mrs X says upon his admission to hospital his urine was recorded as being cloudy suggesting that he was dehydrated because he had not had enough to drink. I have examined the fluid balance charts. They show Mr X was drinking regularly. Mr X had been in his conservatory for a number of hours on a hot day and so this could be an explanation for his cloudy urine. There is no evidence to support a finding of fault with this aspect of the complaint.
  2. Mrs X has expressed concern about whether Mr X was given decaffeinated drinks during his stay as was set out in her care plan. There is no reference to this in the fluid charts or in the assessment or care plan. As this was a specific request and was for health reasons I would expect it to be formally recorded by the Home. The absence of this leads me to conclude that it is possible Mr X was not provided with decaffeinated drinks. This is fault.

Mr X leaving the premises

  1. Mrs X says she left the Home with clear instructions that Mr X should not go out if it was too hot and he should have his mobile with him.
  2. A risk assessment was completed about this. This said staff should be aware of when he was going and for how long and what he was wearing. This implies the Home had accepted some degree of responsibility for, at the very least, being aware of where he was. The care plan itself makes no reference to what should happen when he left the Home.
  3. Mrs X was not told that without a DoLS in place the Home in fact had no legal authority to stop him leaving.
  4. I must consider whether failure to tell her about this amounts to fault. I have decided it does. Mrs X was understandably unaware of the legal restrictions over what control the Home was able to have on Mr X leaving the premises. She left her husband in its care unaware that the Home would be unable to impose the restrictions she had explicitly asked for. The fact the Home included some conditions in its own risk assessment indicates it was not entirely clear on its own legal powers.
  5. Furthermore, on day six, when Mr X had left the Home early in the morning and was returned by a neighbour, his daughter left explicit instructions that he should not be allowed out. Certainly, at this time the Home should have made it clear to her that it had no legal authority to stop him.

Failure to complete an accident form.

  1. An accident form was not competed when Mr X fell at the top of the stairs on day three. It is recorded that he passed out. He was on medication for a heart condition. I would expect an accident form to be completed because a loss of consciousness is a serious matter. While it says the member of staff called the manager there are no records about what she did about this. Neither the family nor GP were called. While this may have been considered unnecessary, I would expect to see some record of the rationale for not doing so.
  2. In response to my enquires, the Home has told me that since this incident the Home had introduced a more rigorous accident reporting procedure. Mrs X has also told me that she is aware that the Home appear to have improved their practices and procedures. While I welcome this improvement, what happened when Mr X fell at the top of the stairs should have prompted more stringent action and proper records made. This is fault.

What happened on day six

  1. Mrs X was understandably concerned that Mr X was admitted to hospital when she believed she had left Mr X in safe hands while she went abroad. I have read the neighbour’s written account of events on day six. It is clear Mr X was not in good health at that time.
  2. There is an argument that due to the deterioration in his mental health as a result of the UTI that he had lost capacity, albeit temporarily, and so the Home could have made a best interest decision to prevent him leaving. However, it is not possible, after the event, to make a finding about this.
  3. There is another argument that Mr X should have been more closely monitored once he was brought back to the home by his neighbour. His daughter had told the Home he was not to go out again. And the notes show Mr X was in a state of distress and was complaining about his catheter being blocked.
  4. It is also arguable, once the Home realised he was missing and had left via the fire exit, knowing he had a UTI it should have done something about it. It was recorded at 11.30 that he had left. He was described in the case records as “agitated”. The next record is from 13.00 when the neighbour contacted the Home.
  5. In its response to my enquiries the proprietor of the Home has, in my view downplayed the incident saying, “other than the fact Mr X had left the building, as he was inclined to from time to time, the details of events that took place in his home were not know to staff and hence not recorded as an accident”.
  6. This is an unacceptable response. The Home knew he was ill and by anybody’s reasonable interpretation, leaving via a fire exit by a 93 year old gentleman, is an unusual thing to do and should be cause for concern. Particularly as he had already been out, before breakfast and had been returned by a concerned neighbour having complained about a blocked catheter and being in pain. He had already been diagnosed as having a suspected UTI by his GP the previous day. Yet the Home did nothing. The very least they should have done was alert his daughter who later phoned to see how her father was, assuming he was back at the Home. I note there is reference to the carer trying to find him but this was as far as any proactivity went.
  7. It is not possible to say whether this lack of action or notification had a direct impact on Mr X’s health but on balance I have decided the Home’s casual approach fell short of the standard of care that would be reasonably be expected and is fault.

Refusal to refund care costs

  1. There is a difference of opinion about what happened once Mr X, having recovered in hospital, was ready for discharge. The Home says, in accordance with its standards procedures, it was required to assess Mr X in hospital to determine if it was still able to offer him the care and support he needed. A carer recorded a conversation he had with Mr X’s daughter telling her this.
  2. In contrast, Mrs X says her daughter was told by the Home that it did not have sufficient staff to watch Mr X all the time and so could not meet his needs. This was confirmed by the manager.
  3. So the family found another care home who could take him.
  4. Shortly afterwards, Mrs X says the Home came to the hospital to carry out an assessment. This was confusing to the family as they say they had already been told the Home was not able to care for him. When the family informed the Home Mr X would be going elsewhere the manager said she felt they could not have him back anyway and would discuss a refund with the owner. This was subsequently refused by the owner.
  5. It is entirely correct and in accordance with the Home’s standard terms and conditions for Mr X’s room to be kept available while he was in hospital. The Home should also assess prior to having him back which they did. The issue here is the different version of events.
  6. It is not possible for me to determine exactly what happened but, on balance, it is unlikely that the Home would have visited Mr X in hospital if it had already decided he could not return. This is supported by the Home’s records. On balance, I have determined there was no fault here.

Conclusion

  1. The service provided to Mr X fell below the required standards, caused in part by the poor initial assessment and care plan. To what extent is unclear because of some poor record keeping. I note the Home has since reviewed many of its practices around this which I welcome. But what happened during his stay caused both Mr and Mrs X avoidable distress and anxiety to such an extent that the purpose or Mr X going to the Home i.e. to give Mrs X a break, was defeated.

Agreed action

  1. To remedy the injustice caused by the faults identified in this decision statement the Home has agreed to:
      1. Apologise in writing to Mr and Mrs X.
      2. Refund the full of the cost of the placement. This is to recognise the purpose of the placement, to provide respite care, not being met. Most of what happened could have been avoided had a proper assessment been carried out, with the involvement of Mrs X, at the outset. This shall be paid in three monthly installments.
      3. Analyse this case again in light of this decision and review its procedures particularly around assessments and recording. It should provide the Ombudsman with a report setting out what action will be taken to ensure this situation does not arise again.
  2. This agreed action should take place within four weeks from the date of my final decision.

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Final decision

  1. There was fault with the service provided to Mr X during his period of respite care. The Home has agreed a suitable remedy.

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Investigator's decision on behalf of the Ombudsman

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