Summary: Mrs B complains on behalf of her husband about the care he received during a respite stay at Acorn Court Care Home. The Ombudsman finds there was fault by the care provider and that this led to injustice for which a remedy has been agreed.

The complaint

1. The complainant, whom I shall call Mrs B, complains about the care provided to her husband, who has Parkinson’s disease and Lewy body dementia, when he was a resident for two weeks at Acorn Court Care Home. She says he was unshaven for several days, and not dressed at 2.30 in the afternoon. On his return home he had a urinary tract infection and sore throat, which Mrs B attributes to inadequate fluid intake and poor continence care.

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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 or others. 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)

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. 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)

Other legal and administrative information

7. 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 fundamental standards include person-centred care, safe care and treatment, and good governance (which includes record-keeping).
8. The 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. It also has power to enforce against breaches of fundamental care standards and prosecute offences.

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How I considered this complaint

9. I considered all information submitted by Mrs B in support of her complaint. I made written enquiries of the care provider and took account of the information it provided in response. I provided Mrs B and the care provider with a draft of this decision and took account of the responses received.

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What I found

10. Mr B was self-funding in Acorn Court nursing home for a two-week respite stay in September 2018. The cost was £1300 a week. The pre-admission assessment noted Mr B would need help with all aspects of his personal care (including personal hygiene and dressing).
11. Mrs B reports that at the end of the two-week period when she went to Acorn Court at 2.30pm to collect her husband and take him home, she found he was in pyjama bottoms, which were wet. She found that when she changed him, his bottom was sore. She called a doctor as he was not acting normally: he was then diagnosed with a urinary tract infection and a sore throat. Mrs B also reports that her husband was unshaven: he appeared to have three days’ beard growth.

Mrs B complains to the care provider

12. When Mrs B complained to the care provider, it acknowledged receipt and said it would investigate and reply if possible within seven days. It did not reply within that timescale, taking 16 days. Contrary to good practice, there is no published complaints procedure clearly available on the website for Acorn Court or its parent company Carebase (Redhill) Limited.
13. In its response to Mrs B’s complaint, the care provider said it had conducted a full investigation and the delay in the response was because of the large number of staff involved in Mr B’s care.
14. Regarding personal care, the response said it had been documented and confirmed with the nurse who was on duty that in the morning on the day Mrs B came to collect her husband Mr B had declined his personal care on two occasions when it was offered. It said at this stage the team members assigned to him would go and help the next residents on their list. The provider acknowledged Mrs B’s concerns that it was 2.30prn and Mr B was still in his pyjama bottoms but said staff had to respect his wishes and that it was documented that he had declined. It said this was the only day that Mr B had declined care from the team. It said records showed that Mr B received either a shower or ‘personal care’ but did not record a shave as a separate entry and so it could not confirm when he was shaved. It said all the team members had now been asked to record the individual tasks that they undertook for example, shower or bath, oral care, and shaving.

Response to the Ombudsman’s enquiries and what the evidence shows

15. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 include a requirement that care providers maintain securely an accurate, complete and contemporaneous record for each service user, including a record of the care and treatment provided to them and of decisions taken in relation to that care. Records must be accurate. The provider’s own policy in respect of record keeping notes that records should include all information that would help the next health or social care worker to ensure consistency in providing care.
16. The daily care records for the relevant morning state clearly:
    “08.30 shower. [Mr B] was assisted with personal and oral care, pad changed, applied cream and put on daily clothes”.
    This does not support the response the care provider gave to Mrs B, as set out in paragraph 14 above. There was no reference to refusing care and in fact the records suggest the opposite: that Mr B had accepted personal care and was appropriately dressed.
17. Asked to comment on the discrepancy the care provider said information presented was accurate and communication had been misinterpreted or misunderstood. It says Mr B did have personal care and that at the time it was looking for missing items of clothing and trousers were not available: it says Mr B declined to wear his shorts and asked that clean pyjama bottoms be put on him instead.
18. I do not consider there is any evidence here to support the view that there has been any misinterpretation or misunderstanding of information. The information the care provider has presented to the Ombudsman is at odds with what it told Mrs B, and its daily care records do not support either version. This casts doubt on the accuracy of the home’s record keeping. This poor record keeping was fault.
19. There are further examples of this in respect of other aspects of Mr B’s care. His care plan noted for example that he had a medium risk of pressure sores and should have a repositioning schedule tailored to his needs plus daily or weekly documented checks of his skin. While such care may have been provided, it is not documented in the daily care records. Regarding nutrition, his care plan noted he was not at risk of malnutrition but needed prompting at times. But the daily care records in respect of hydration and food intake appear very inconsistent. On one day, the only liquid intake recorded was 200ml of tea at 3pm. On another day the record refers to Mr B having consumed the offered 600ml of soup, but the same record says he at half his soup: both cannot be correct. Regarding food intake, the records for one day for example include two entries for breakfast, with one at 8.39am stating Mr B had eaten all his cooked breakfast and cereal, and another entry at 10.45am by the same member of staff recording he had eaten ‘some cereal some of his cooked breakfast’. Regarding continence care, the records appear incomplete: for example, on one occasion a pad change is recorded at 10.15pm with the next at 11am the following day.
20. While I cannot conclude that Mr B received poor care leading to the infection which was diagnosed once he returned home, the poor record keeping means there is doubt about the care he received at Acorn Court. There may have been injustice to Mr B if he did not receive the full care to which he was entitled, and there is injustice also to Mrs B who paid for the care and is left with a justifiable sense of concern about how her husband was cared for during his respite stay.

Agreed action

21. In recognition of the injustice identified above, I recommended that within four weeks of the date of the decision on this complaint, the care provider:

• pays Mrs B a sum equal to half the sum she paid for her husband’s stay at Acorn Court; and
• issues Mr and Mrs B with a formal written apology.

22. The care provider has said its staff are constantly reminded about the protocol for recording care given, and its in-house trainer is producing a training pack which will cover this issue. To ensure that this improvement is put into practice, I recommended that within three months of the date of the decision on this complaint the care provider submits evidence to show that since September 2018 all care staff at Acorn Court have undertaken training or refresher training in respect of record keeping.
23. The care provider has agreed to my recommendations.

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Final decision

24. I have completed my investigation on the basis set out above.
25. Under our information sharing agreement, we will share the final decision on this complaint with the Care Quality Commission.

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Investigator's decision on behalf of the Ombudsman