Summary: Some of the care provided to Mrs Y at a residential care home was below an acceptable standard. The care home failed to properly record decisions made by a CPN, and failed to communicate this decision, and other information about Mrs Y’s health to her daughter. The company accepts failings in its practice and has made improvements. We have made recommendations to address the injustice caused to Mrs Y and her daughter.

The complaint

1. Mrs X complains about the quality of care provided to her mother, Mrs Y at Asprey Court Residential Care Home. She says:

• her mother was without regular medication for several weeks
• she was not informed when her mother had a fall and an ambulance was called
• she was not informed when her mother was moved to another unit with the home
• staffing levels at the home were insufficient
• communication was poor
• staff did not attend a Continuing Health Care meeting or provide adequate information about Mrs Y’s care needs.

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The Ombudsman’s role and powers

2. 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)

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How I considered this complaint

3. I have:

• considered the complaint and discussed it with Mrs X;
• considered correspondence between Mrs X and the Care Provider including the Care Provider’s response to the complaint;
• made enquiries of the Care Provider and considered the responses;
• taken account of relevant legislation;
• offered Mrs X and the Care Provider an opportunity to comment on a draft of this statement, and considered the comments made.

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What I found

Relevant legislation

4. 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.
5. One of the fundamental standards (regulation 9 of the regulations for service providers and managers) is about person-centred care. Each person should receive person-centred care and treatment, based on their individual needs.
6. Standard (regulation 12) is about safety. Care providers should not put people receiving care at risk of harm that could be avoided. It says care providers should be able to show they have taken all reasonable steps to ensure the health and safety of those receiving care.
7. Standard (regulation 16) is about complaints. This says staff must know how to respond when they receive a complaint, and this can be verbal. Care providers must thoroughly investigate complaints. This includes keeping records of complaints and actions taken.
8. Standard (regulation 17) is about good governance. This includes keeping accurate, complete and detailed records about people receiving care, including records of care provided and decisions made relating to care.

Background

9. Mrs Y has Alzheimer’s Disease and a history of mental health issues. She went into the care home on 1 June 2018 as an emergency admission following the breakdown of a placement at a different care home. She was reported to need 1-1 care and was placed in the care home’s complex care unit.

Mrs X says

10. Mrs X says she became concerned about changes to Mrs Y’s behaviour a few weeks after Mrs Y went into the care home. Mrs Y appeared to increasingly agitated and distressed. At the time, Mrs X could not understand the deterioration. She says it was distressing to witness the change in Mrs Y.
11. In early August 2018, Mrs X discovered Mrs Y had been without dementia medication since the end of June 2018. Care staff had not informed her of any changes to Mrs Y’s medication. Mrs Y had a sufficient supply of the drug when she went into the care home. Mrs X believed care staff had run out of the medication because it had been lost or administered incorrectly Mrs X believed the care home then failed to re-order the medication.
12. Mrs X believed care staff had not informed the CPN that Mrs Y had been without dementia medication, and was the likely cause of her changed behaviour. She also believed care staff failed to alert the GP.
13. Mrs X says had she been informed of changes to Mrs Y’s medication, she could have explained the necessity of the dementia drug, and Mrs Y’s symptoms could have been relieved sooner. Mrs Y began receiving the medication again on 9 August 2018.

14. Mrs X says she now believes the CPN instructed care staff to reduce the anti-psychotic medication but not to make changes to the dementia medication.
15. Mrs X attended a Continuing Healthcare (CHC) assessment meeting on 10 August 2018. She was unhappy the assessment took place on a unit Mrs Y had recently moved to, and that the staff member present did not know Mrs Y well. She believed the CHC assessor was not given accurate information about Mrs Y’s needs because care staff failed to record her mother’s behaviour or keep behavioural charts.
16. During the CHC meeting, Mrs X discovered Mrs Y had fallen on 9 June 2018 and an ambulance had been called. She was also told Mrs Y had been diagnosed with a urine infection. Mrs X was not informed of either incident.
17. When Mrs X visited Mrs Y on 23 August 2018 there appeared to be only one carer on the unit, and the carer had no knowledge of Mrs Y’s whereabouts. Mrs X believed the staffing on the unit was insufficient.
18. Mrs X was not happy with the care provided and the lack of communication from care staff. She made a formal complaint to the Director of the company on 25 August 2018. She received an email on 28 August 2018 acknowledging her complaint.
19. Mrs X did not receive any other correspondence about her complaint until after she contacted the Ombudsman in February 2019, following which, she received a copy of a complaint response letter dated 11 December 2018. Mrs X says this was the first time she had seen this letter.
20. Mrs X says her concerns led her to look for a different care home. When she found a suitable home with a vacancy she decided to move Mrs Y immediately. Mrs X was aware of the care home’s 28-day notice period but she believed it was in Mrs Y’s best interest to move quickly. Mrs X accepted Mrs Y had to pay care fees for the notice period.
21. Three months after the move Mrs Y had a further CHC assessment and CHC was awarded. Mrs X says Mrs Y’s needs were unchanged from the previous assessment apart from her behaviour, which was more stable because she was taking regular medication.

The Care Provider’s response to the Ombudsman’s enquiries

Medication

22. The Care Provider says due to the nature of Mrs Y’s admission the care home did not have all Mrs Y’s medical information. This was obtained after admission and the care home completed a detailed care plan. I have seen a copy of this document. This records Mrs Y was prescribed dementia and anti-psychotic medication, and a night-time sleeping tablet.
23. The care home completed a ‘Mars’ medication record which recorded all the medication Mrs Y was admitted with. I have seen a copy of this document. It records Mrs Y had 46 dementia pills on admission, she was prescribed one tablet daily.
24. On 3, 4 & 22 June 2018 carers recorded Mrs Y refused medication.
25. The medication records show a GP visited Mrs Y on 20 June 2018 and made a change to one of Mrs Y’s medication. A Community Psychiatric Nurse (CPN) visited Mrs Y on 27 June 2018 and reviewed her medication. The records show she stopped the dementia and antipsychotic medication. Mrs X was not informed about this.
26. The Care Provider says the staff member on duty stopped the medication as instructed by the CPN, destroyed all remaining medication and recorded it on Mrs Y’s ‘MAR’ medication record, but she failed to update Mrs Y’s medication care plan and daily records. This caused confusion between care staff. Care staff contacted the Community Mental Health Team (CMHT) to request a prescription for the dementia medication because they were unaware the medication had been stopped. Because the medication had been stopped no repeat prescription was sent to the pharmacy.
27. The care home completed behaviour records for Mrs Y (ABC charts). I have seen copies of these records. The records show an increase in Mrs Y’s agitation and distress after the dementia medication ended. The care home applied for a Deprivation of Liberty authorisation (DOLS) on 27 June 2018 because Mrs Y was distressed and trying to leave the building.
28. The care home reported Mr Y’s changed behaviour to the CMHT on 6 July 2018. A CPN visited Mrs Y on 10 July 2018. Care staff told the CPN that Mrs Y was not taking dementia medication. The CPN contacted the CMHT to discuss the matter with Consultant Psychiatrist the same day. The Psychiatrist was not available. A repeat prescription was issued at some in July 2018. Mrs X did not receive the dementia medication until 9 August 2018. Anti-psychotic medication was reinstated in on 24 July 2018.
29. The Care Provider says at the time this occurred, the care home did not have robust procedures in place with the CMHT and GP’s. Following this complaint, the care home has implemented new arrangements with a local GP practice and CMHT. A GP visits twice weekly, along with a CPN. Families are also invited to attend. CPN’s now document all decisions/actions in the care home’s records, and GP’s and CPN’s now contact all relatives to inform them of any changes made to resident’s care.
30. The Care Provider say that in Birmingham GP’s do not prescribe dementia drugs or mental health drugs, CMHT hold this responsibility, and this has caused some issues when residents move to the care home. The care home addressed this during a multi-disciplinary meeting with the GP, CMHT and the Clinical Commissioning Group. As a result, working practices are more collaborative. This avoids any gap in service for new residents.
31. In addition to this, all care staff responsible for medication have undergone further training and supervision.

Continence

The care records show Mrs Y was incontinent of urine on 13 August 2018, and that she had been distressed about this. A carer recorded Mrs Y asked if she could wear a pad. Pads were provided. Carers recorded Mrs Y’s urine had a strong odour. The GP was informed and Mrs Y was found to have a urine infection. The Care Provider acknowledges Mrs X was not informed.

Staffing

32. The Care Provider has provided me with a copy of the staffing rota for the 23 August 2018 on the unit which cared for Mrs Y. This shows, there was one nurse, and six care staff, two of which were senior, on duty. There were eighteen residents, six of which had 1-1 supervision for activities. The care home did not keep records of care staff supporting residents with activities. It says it not possible to explain why there seemed to be an absence of staff at the time Mrs Y visited.

CHC assessment meeting

33. The records show a CHC assessment meeting was held on 10 August 2018. A CHC assessor conducted the assessment. A staff member from the care home was present, along with Mrs X’s daughter.
34. The CHC assessor had access to all the care home’s electronic care records. I have seen copies of the care records made available to the assessor. The records are detailed and give a full overview of Mrs Y’s needs and the care provided by care staff and all involvement from NHS professionals from the day of admission.
35. The NHS wrote to Mrs X on 17 August 2018 to inform her of the outcome of the CHC assessment. The author said Mrs Y had not met the eligibility criteria for CHC because she did not have a primary medical need. However, she met the criteria for NHS funded Nursing care, and a weekly payment of £158.16 towards her care would be paid directly to the care home. The award was backdated to 3 July 2018.

Mrs Y’s fall

36. In its response to my enquiries, the Care Provider refers to an attached report from the ambulance service. However, the report was missing from the information I received. I contacted the Care Provider on two occasions to request a copy of the report. I have not received it. It is fair to assume, given the Care Provider’s reference to it, that such a report exists. This supports Mrs X’s claim that Mrs Y had a fall and the ambulance service attended the care home. This is not recorded in Mrs Y’s records. This is fault. Mrs X was not informed. This is also fault. Mrs X says she was upset and angry by the way care staff responded to her enquiries about the fall. Care staff dismissed her concerns and queries and said no such incident had occurred. The care provider should apologise for this.

Complaint handling

37. The Care Provider acknowledges it received a complaint from Mrs X on 25 August 2018. An acknowledgment was sent to Mrs X and the complaint was passed to the deputy manager of the care home to investigate, and report her findings to the manager; and send a response to Mrs X. The deputy manager told the Care Provider this had been actioned and completed. The Care Provider says it now realised this was not the case, and Mrs X had not received a response to her complaint.

Analysis

38. People are entitled to safe, effective and high-quality care. In this case the Care Provider fell short of these standards. The Care Provider failed to reach the Care Quality Commission’s fundamental standards, particularly in terms of person-centred care.
39. The Care Provider acknowledges that at the time of this complaint its practices and procedures fell short of what is acceptable, and that it has taken robust action to address this.
40. It is clear from the records Mrs Y went into the care home under very difficult circumstances. The care home was unable to complete a detailed assessment of Mrs Y’s needs on admission. Given the circumstances, this is understandable, and not one which can be criticised. When the care home did complete an assessment, it did so to a good standard. The assessment is detailed and comprehensive. The care home also acted swiftly and appropriately in making a DOLS application for Mrs Y, and completed mental capacity assessment paperwork properly. This was good practice.
41. One of Mrs X’s concerns relates to record keeping. The records I have seen show care staff kept detailed contemporaneous daily care records. For the most part, there is evidence of good practice.
42. Mrs X believes the care home stopped Mrs Y’s dementia and anti-psychotic medication, this was not the case. This decision was made by a CPN, and one which care staff had no control over. However, a staff members failure to properly document this decision in Mrs Y’s records, and update her care plan led to confusion between care staff and clinicians, and resulted in Mrs X being unaware of the decision. I have seen no evidence which shows a CPN told care staff to reduce anti-psychotic medication only.
43. This resulted in incorrect beliefs about why Mrs Y was without dementia medication. This caused Mrs Y unnecessary distress and a degree of distress to Mrs X. Had the staff member correctly documented the CPN’s decision, and informed Mrs X, the issue may have been resolved sooner. Following a decision to reinstate the dementia medication in July 2018, there was a delay in Mrs Y receiving it. It is difficult to understand why this happened, particularly when the anti-psychotic medication was reinstated on 24 July 2018.
44. Communication between the care home staff and Mrs X was poor. Mrs X was not informed that Mrs Y had been diagnosed with a urine infection. This is fault. Had Mrs X been informed she would have understood why Mrs X needed incontinence pads.
45. In relation to Mrs X’s concerns about staffing. I find no fault here. The Care Provider has provided evidence to show the unit caring for Mrs Y was adequately staffed. It is not possible to know now, why there was only one carer available when Mrs Y arrived on the unit. Her concerns about this are understandable. By this point she had begun to lose confidence in the care home, and this only reinforced those concerns.
46. Mrs X believes her mother was refused CHC funding because the CHC assessor did not have sufficient or accurate information about Mrs Y’s needs. Mrs X was concerned the staff member present at the meeting was not familiar with Mrs Y. This may have been the case but it had no impact on the assessment. The records available to the assessor gave a full picture of Mrs Y’s needs, and included completed behavioural charts. I find no fault by the care home here.
47. Decisions about CHC funding are taken by the NHS. Following the CHC assessment, Mrs Y was awarded NHS funding towards the cost of nursing care. Mrs Y had the option to submit an appeal to the NHS if she disagreed with this decision.
48. The Care Provider accepts its complaints procedure was not correctly adhered to in this case. This caused additional frustration for Mrs X. The Care Provider has apologised to the Ombudsman.
49. I am satisfied the Care provider has taken robust action to address the failures identified in this complaint. I do not propose to make further recommendations in relation to this.
50. The Care Provider’s failings caused an injustice to Mrs Y and to Mrs X. A remedy for both is required. Mrs Y suffered distress which was prolonged because of the care home’s failure to properly communicate and record a decision made by a CPN, and an unexplained delay in the medication being reinstated. It is more by good luck than good management that there were no serious ramifications.
51. Mrs X witnessed Mrs Y’s increased distress. This caused her upset and worry. She has been put to significant time and trouble pursuing her complaint with the Care Provider and the Ombudsman.
52. Under the terms of our ‘Memorandum of Understanding’ I intend to send a copy of the final decision statement to the Care Quality Commission.

Agreed action

53. The Care Provider will within four weeks of the final decision:

• provide Mrs X with a sincere written apology for the failures identified in this complaint;
• pay Mrs X £250 in acknowledgement of her frustration and the time and trouble she has been out to pursuing the matter;
• re-imburse Mrs Y the full fees paid for the notice period after she left the care home.

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Final decision

54. The Care Provider accepts some failings in its practice. This does not go far enough. To remedy the injustice caused to Mrs Y and Mrs X the Care Provider should carry out the above recommendations.
55. It is on this basis; the complaint will be closed.

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Investigator's decision on behalf of the Ombudsman