Summary: Mr X complained on behalf of his mother in law, Mrs Y, about care provided during a respite stay at a care home. There were faults in the care provider’s record keeping and care planning. These caused uncertainty to Mrs Y and Mr X about the adequacy of care provided. The care provider agrees to apologise to Mrs Y and Mr X, make a token payment of £250 to Mrs Y acknowledging distress caused to her, and review its practice to prevent reoccurrence.

The complaint

1. Mr X complains on behalf of his mother-in-law Mrs Y about care provided during her respite stay at a care home run by Care UK Community Partnerships.
2. He says the home did not provide her with a specialist mattress she needed, did not always carry out two hourly checks as agreed and did not change her incontinence pads or assist her to use the toilet as requested. It did not ensure she ate adequately during her stay. Mr X says Mrs Y left the home with bruising suggestive of poor handling.
3. He believes Mrs Y suffered a urinary tract infection, bruising and distress because of these faults.

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The Ombudsman’s role and powers

4. 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)
5. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
6. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
7. 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)
8. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

9. I spoke to Mr X about the complaint and considered records provided by the care provider.
10. I made third party enquiries of the council that carried out a safeguarding investigation.
11. I considered the Ombudsman’s guidance on remedies.
12. I gave the care provider and Mr X the opportunity to comment on my draft decision.

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What I found

13. 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.
14. The fundamental standards say the care and treatment of service users must be appropriate, meet the person’s needs and reflect their preferences. The care provider must assess the person’s needs and preferences and design care and treatment to meet these needs.
15. When someone stays in a care home for respite care, the provider should assess the person’s needs. It must develop a clear care plan which includes agreed goals. The provider must make this plan available to all staff and others involved in providing the care.
16. Care providers must keep accurate, complete and current records for each person in their care, including a record of the care and treatment provided and decisions about care and treatment.
17. 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. It also has power to enforce against breaches of the fundamental care standards and prosecute offences.

Background

18. Mrs Y went to stay at the care home in November 2018 for a short respite stay. Mrs Y has a range of physical health problems and care needs. The care provider assessed her before she went to stay. The care provider says Mr and Mrs X were at the assessment. The assessment recorded she needed help with toileting, personal hygiene, eating and with transfers to bed. It recorded she was at risk of malnutrition and referred her to a dietitian.
19. A body map recorded a red area on Mrs Y’s spine and thin skin. The care provider carried out risk assessments for eating hot food and drink, getting into and out of her wheelchair and said she needed a low profile bed which was standard at the home. The manager referred Mrs Y to a district nurse to check the marks on her back.
20. The care provider weighed Mrs Y when she was admitted. The weight recorded showed she was at high risk of malnutrition. The care provider’s policy is that a referral is only made after a further three days of monitoring. It referred Mrs Y to the dietician after the fourth day of her stay, following this monitoring.
21. The care provider prepared a care plan for Mrs Y’s stay. It said she needed assistance from one carer with “all aspects of personal care as well as dressing”. It stated “[Mrs Y] likes to be assisted to the toilet every two hours due to being blind she needs to be assisted by one carer, she wears incontinence pads for protection”.
22. The care plan also said “[Mrs Y] likes to be told what the food is on her plates she will not eat if she has not been told what it is” and “ to be offered food… and given choice, food to be cut up and [Mrs Y] to be told what it is”
23. Mr X told me he is sure he showed Mrs Y’s air flow mattress to the care home manager and that the manager told him the home would provide this. The care provider does not recall this conversation. The assessment and care plan do not refer to Mrs Y needing a specific type of mattress. The care provider says it only provides an air flow mattress if a district nurse decides it is necessary.
24. Mrs Y’s care records set out the help given to her with various daily tasks. Records for some days specifically refer to her being checked every two hours, and sometimes that she was assisted to the toilet every two hours. On other days the records are more general in respect of frequency and type of care. For example, on several days they record that Mrs Y was “assisted to the toilet throughout the day”.
25. The care records do not specifically refer to staff telling Mrs Y what was on her food tray or to cutting up her food. They record more generally such as “[Mrs Y] was taken a tray for lunch and has had a good food and fluid intake”, “[Mrs Y] was taken a tray and has had a small diet” and “has taken a poor diet at lunch time and tea time”.
26. Several days after admission the care provider noted signs Mrs Y had a urinary tract infection. It reported this to her GP. She started on antibiotics. Care notes also record concern about her skin condition. The care provider referred this to the district nurse. The records state the care provider wanted to check if Mrs Y needed to use an airflow mattress. They show the district nurse checked and the home ordered extra cushions and support to protect her.
27. Records also refer to concern about Mrs Y’s appetite and that she was referred to a dietitian although the dietitian’s schedule meant they did not visit the home until Mrs Y had left. The home provided the dietician with Mrs Y’s home address to follow up the contact.
28. At the start of December, Mrs Y’s airflow mattress used by Mrs Y at home was brought to the care home. She used this for the rest of her stay. Mrs Y ended her respite stay at the home later that month.

Mr X’s complaint and responses

29. Mr X complained to the care provider about Mrs Y’s care and condition after leaving the home. The care home manager replied in December saying staff told Mrs Y what her meals were, changed her incontinence pads when necessary and encouraged her to use the toilet every two hours. They said carers had not seen bruising when she left.
30. In January 2019, after further investigation, the care provider head office replied having interviewed the manager. It said its admission record did not say Mrs Y needed an airflow mattress. It said it would change procedures to specifically ask at admission whether residents need this type of mattress.
31. The care provider said care records showed Mrs Y preferred help using the toilet every two hours and to wear pads. It said her care records indicated she was taken every two hours but that sometimes the pad had not been used so it was not changed. Leaving dry pads on for longer would not normally lead to infection. It apologised for not respecting Mr X’s wishes on this matter. It said it would learn from the complaint, ensuring it kept accurate records of regular toileting assistance.
32. The care provider said it knew Mrs Y was at risk of malnutrition. It had referred her to a dietitian because of concern. It had taken food to her and care staff had explained where it was. It had monitored her food and fluid intake.
33. The care provider had not recorded Mrs Y’s skin condition when she left the home so had no record of marks. Staff could not recall any marks on her skin during her stay. It referred to Mrs Y wearing a skirt so this would have been visible. It referred Mr X to the Ombudsman.
34. Mr X replied to the care provider in February 2019 with further concerns:
• He would have brought the mattress at the start of Mrs Y’s stay if he had not thought the home would provide one.
• The care home had not adequately documented its care of Mrs Y including the two hourly toileting help. This was important to prevent infection. Mrs Y had returned home with unused pads that indicated the home had not changed them often enough.
• The care home had not helped Mrs Y eat by telling her what food was on her plate. This was particularly important given her blindness. Food had not always been cut up for her.
• Mrs Y did not have any skirts to wear during her stay so the record about skin marks could not be true. The marks when she left the home suggested lack of care moving her. They had disappeared since she left.
35. Because of contact between Mr X and the CQC, the council held a safeguarding meeting in April. Mr X was invited but did not attend the meeting. The meeting concluded with action for the care home to consider measuring people’s weight at admission, even for short term respite stays, to get a baseline for future measurements. The care provider challenged the findings as it had recorded Mrs Y’s weight at admission. A joint visit was made to Mr and Mrs X about the outcome of the meeting.
36. Mr X told me he had given the home detailed instructions about how Mrs Y liked her food. He said it had ignored this and she had lost a lot of weight at the home. It had also ignored the instruction to change her pads (whether wet or not) every two hours. After reviewing notes of the safeguarding meeting Mr X raised concerns with the council about its outcome.

My findings

Mattress

37. Mr X and the care manager’s recollections of discussion (before admission) about the mattress Mrs Y needed differ. There is no contemporaneous record, other than the pre-assessment form which does not refer to this. In a situation where recollections differ I cannot say what was discussed or agreed. Therefore I cannot reach a finding on this matter. The care provider has agreed to ask if such mattresses are needed in future. This will prevent avoidable uncertainty of this kind from now on.

Help with the toilet

38. Mrs Y’s care plan said she liked to be assisted to the toilet every two hours. It did not make clear whether this “like” was a requirement that carers had to follow or a more general preference. The plan talked about this in the section “current situation”. The subsequent sections for “expected outcome” and “actions” were left blank.
39. The fundamental standards expect that care plans must set out agreed goals. This is the same standard for plans about long-term and shorter respite stays. This lack of clarity about actions in Mrs Y’s care plan was fault. It meant Mrs Y’s carers did not have clear instructions about the frequency of toileting assistance Mrs Y needed.
40. Neither the assessment or care plan refers to the need to change Mrs Y’s pad (whether wet or dry) every two hours. Although Mr X is sure he emphasised this at admission, these documents were the agreed basis for her care. Therefore, I cannot say it was fault not to change the pads more regularly.
41. The assessment and plan provided in evidence are not signed by Mrs Y’s relatives though Mr X has not disputed their accuracy. This is fault in record keeping. The care provider should ensure it retains signed copies of such documents to demonstrate they have been shared and agreed with relatives.
42. The care records, up to the point Mrs Y developed a urinary tract infection, refer to assistance with toileting, and with hourly checks throughout the night. From this evidence I cannot say that the care provider’s fault in care planning directly led to Mrs Y’s infection. I cannot say that more frequent checks would probably have prevented this. However, the fault has left Mrs Y and Mr X uncertain about whether the outcome would have been different, but for the fault. This caused them avoidable distress.

Eating

43. The assessment and care plan state Mrs Y needed care staff to tell her what she was eating each time food was prepared. They say she must be given a choice of food. Care records noted only that she was taken food. They do not record that carers told her what was on the plate, or that she was given a choice. The care provider told the safeguarding meeting Mrs Y would have been given a choice, each time from two or three options but there is no contemporaneous record of this.
44. Given the specific requirement in Mrs Y’s care plan, the care provider should have ensured it always recorded carers telling Mrs Y what food she had to eat for each meal. The care provider’s food records show Mrs Y sometimes refused food offered or only ate some of it. Although the records are mostly complete, some do not indicate how much (if any) food Mrs Y ate. Some records are not signed by care staff. These are all faults in record keeping.
45. The care provider weighed Mrs Y at admission and highlighted concern about her low weight at that time, appropriately alerting a dietician after further monitoring in line with its policy.
46. It is impossible to say whether the faults with food records and with clarity on carer assistance affected Mrs Y’s weight. They have, though, left Mrs Y and Mr X uncertain about whether they contributed to Mrs Y’s low weight. This caused them avoidable distress.

Bruising

47. The care home failed to record Mrs Y’s skin condition when she left the home. This was fault. Mr X thinks marks on her skin he noticed after discharge were caused by handling at the home.
48. Again, the care provider’s lack of records has caused avoidable uncertainty and distress to Mrs Y and Mr X about what happened. It should ensure it always records skin conditions at arrival (as it did) and again at discharge.

Safeguarding

49. Mr X has concerns about the adequacy of the council’s safeguarding investigation. He can complain to the council and ask it to consider his complaint before deciding whether to complain to the Ombudsman.

Agreed action

50. Within one month of my final decision the care provider will:
• Apologise to Mrs Y and Mr X for uncertainty caused to them by the failures identified in care planning and record keeping
• Pay Mrs Y £250 as a token remedy for distress caused to her by these faults.
51. Within three months the care provider will have:
• Delivered training for staff carrying out care assessments and care plans to ensure these always result in clear, agreed goals as required by the Fundamental Standards. Also to ensure staff keep care records that detail where care has been given in accordance with these clear, agreed care plan goals. It should provide the Ombudsman with evidence that this training has been carried out.
• Implemented action to ensure all residents (whether for long term or respite) have a skin integrity assessment at departure.

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Final decision

52. I have completed my investigation as I have found evidence of injustice caused to Mrs Y and Mr X by the care provider’s actions. The care provider has agreed to take action to remedy this injustice and prevent the faults reoccurring.

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Investigator's decision on behalf of the Ombudsman