Summary: The Ombudsmen find fault by Care UK with regards to the care it provided to an elderly man during his time in a care home in 2017 and 2018. The Ombudsmen have made recommendations to address this fault and the impact it had on the man’s family.

The complaint

1. The complainant, who I will call Mrs D, is complaining about the care provided to her father, Mr J, while he was resident in Brook Court Care Home (the care home) between May 2017 and August 2018. Mrs D complains the care home:

• Failed to reposition Mr J regularly in his bed as his arthritis required.
• Failed to carry out hourly checks and did not provide proper care when they did undertake checks. Mrs D says she often found Mr J partially clothed and in need of changing.
• Did not administer Mr J’s medication (including pain relief) appropriately.
• Did not include Mr J in activities at the care home or provide him with stimulation within his room.
• Failed to provide food of an appropriate consistency for Mr J’s nutritional needs.

2. Care UK (the service provider that operates the care home) was responsible for the care provided to Mr J during his time in the care home between May 2017 and August 2018.

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The Ombudsmen’s role and powers

3. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
4. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

5. In reaching this final decision, I considered information provided by Mrs D and discussed the complaint with her. I also considered information and documentation provided by Care UK, including the care records. I also took account of relevant guidance and legislation.
6. In addition, I considered comments from Mrs D and Care UK on my draft decision statement.

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What I found

Relevant legislation and guidance

Care home regulations and guidance

7. In 2008, the government introduced the Health and Social Care Act 2008 (the Act). This Act created a new regulator of health and social care services in England. This is the Care Quality Commission (CQC).
8. This led to the introduction of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Care Regulations). The Care Regulations set out the fundamental standards those registered to provide care services must achieve and below which care must never fall.
9. The CQC provides guidance for care providers on how to meet the fundamental standards of care. This is entitled Guidance for providers on meeting the regulations (2015) (the Guidance).

Key facts

10. Mr J had complex physical health needs, including severe arthritis and heart disease. He also had vascular dementia.
11. Mr J’s arthritis meant his legs were contracted and he was unable to stand. This meant he needed care to be provided to him in bed. As Mr J could not straighten his legs and was unable to reposition himself, he required regular repositioning from staff.
12. Mr J was resident in the care home between May 2017 and August 2018. He transferred to another care home in August 2018.

Analysis

Repositioning

13. Mrs D said Mr J required repositioning on a three-hourly basis due to arthritis in his legs but that the records showed he was sometimes not moved for far longer than that.
14. Care UK acknowledged there were gaps in the repositioning records. It said it was not possible to determine whether staff had, in fact, repositioned Mr J and simply forgotten to record this.
15. Shortly after Mr J’s admission to the care home, staff carried out a series of risk assessments. This included a pressure area risk assessment. The assessment found Mr J was at high risk of developing pressure ulcers as a result of being largely bed-bound and doubly incontinent. As a result, it was noted Mr J would require regular repositioning throughout the day and night.
16. Mr J’s care plans also show that his arthritis sometimes caused him pain and discomfort. The records show Mr J had a tendency to move around in his bed and required assistance from staff to return him to a comfortable position.
17. From May 2017, the care home maintained repositioning charts for Mr J. These recorded the need for three-hourly repositioning during the day and four-hourly repositioning at night.
18. Regulation 12 of the Care Regulations relates to the provision of safe care and treatment. This regulation stresses the importance of properly assessing any risks to a service user and taking all practicable action to mitigate these risks. It also says that care staff must follow care plans and pathways.
19. I have reviewed the repositioning charts for the duration of Mr J’s time in the care home between May 2017 and August 2018. The charts show there were numerous occasions during this period when care home staff failed to reposition Mr J as frequently as his care plan required.
20. In my view, the evidence suggests the care provided by the care home in this area was not in keeping with the Regulations. This is evidence of fault by Care UK.
21. This placed Mr J at greater risk of developing a pressure ulcer. It also made it more likely he would be left in pain or discomfort for a protracted period.
22. I note that Mr J’s skin was intact at the point of his transfer to another care home in August 2018. On this basis, I am satisfied the fault I have identified in this area did not have a significant impact on Mr J in terms of his pressure ulcer care.
23. Nevertheless, I consider it likely, on balance of probabilities, that the failure to reposition Mr J in accordance with his care plan meant there were occasions during this period when he was left in pain and discomfort. This has in turn caused Mrs D avoidable distress.

Hourly checks

24. Mrs D complained that staff failed to carry out hourly checks for Mr J and did not provide appropriate care when checks were undertaken. Mrs D said she visited Mr J every day and often found him half-clothed and in need of changing with the door to his room open. Mrs D said she raised this with nursing staff at the care home, but they seemed not to care.
25. Care UK apologised if Mrs D felt there were occasions when staff had completed hourly checks but failed to provide the care Mr J required.
26. I have reviewed the welfare check sheets for the duration of Mr J’s time in the care home. These suggest there were occasions when staff failed to check on Mr J as frequently as they should have. Furthermore, I identified several unexplained omissions in the sheets. This is evidence of fault by Care UK.
27. This caused Mrs D distress and uncertainty about the standard of care Mr J received during this period.
28. It is more difficult to comment on the quality of the care offered during the welfare checks that staff did undertake. This is because the sheets offer only basic information about Mr J (such as whether he was asleep, whether staff repositioned him and whether it was necessary to change his bedding).
29. Mrs D says she often arrived to find Mr J unclothed (or in wet clothes and bedding) and with his room door open.
30. In response to my enquiries on this point, Care UK said Mr J often became agitated when staff tried to dress him and frequently kicked off his bedding. Care UK explained it had introduced wraparound incontinence pads for Mr J to protect his dignity but recognised this was “not ideal”. Care UK acknowledged staff usually left Mr J’s door open so staff could check on Mr J as they passed.
31. Regulation 10 of the Care Regulations relates to dignity and respect. Regulation 10(2)9a) says “[e]ach person’s privacy must be maintained at all times including when they are asleep, unconscious or lack capacity.”
32. This is expanded upon in the Guidance for Regulation 13 (safeguarding service users from abuse and improper treatment). Section 13(4)(c) of the Guidance says care and treatment must not be provided in a way that is “degrading for the service user”. The Guidance goes on to include examples of degrading treatment, such as service users being “left in soiled sheets for long periods” or “left naked or partially or inappropriately covered.”
33. Mr J was doubly incontinent and required regular changing. I note Mrs D says there were several occasions on which she arrived at the care home to find Mr J in wet clothing and bedding. I fully appreciate this would have been distressing. However, there is no independent evidence available that would allow me to establish how long Mr J had been left without being changed on those occasions. Similarly, I am unable to say how promptly staff would have changed him if the family had not visited. Therefore, I am unable to make a robust finding on this point.
34. Nevertheless, the Care Regulations and associated Guidance are clear about the importance of protecting a service user’s dignity and privacy.
35. I acknowledge Mr J’s behaviour sometimes made it difficult for care home staff to keep him dressed and covered. However, this should have led the care home to place greater importance on protecting his dignity where possible. In my view, by continuing to leave Mr J’s room door open so he could be viewed by staff and other residents, the care home risked significantly compromising his dignity. This was not in keeping with Regulations and is evidence of fault by Care UK. This caused Mrs D additional distress.

Medication

36. Mrs D said Mr J was in constant pain from his arthritis and required paracetamol four times a day as well as analgesic gel on his legs. However, she said the care home used an unsuitable pain tool and failed to administer Mr J’s pain relief medication appropriately. Mrs D said staff also failed to administer Mr J’s other medication (such as eye drops for glaucoma and heart disease medication).
37. Care UK said Mrs D raised concerns about the Mr J’s pain relief on in June 2018 and this led to the introduction of the Abbey Pain Scale (a specialist tool for patients with dementia or learning disabilities who are unable to vocalise pain). Care UK said the care home agreed to commence the analgesic gel three times per day, with the paracetamol being used as required.
38. Mr J’s care plans record that he suffered from arthritis. This caused pain in his neck, legs and lower back. The plans note staff should “ensure [Mr J] is receiving pain relief, and regular medication to maintain health and wellbeing.”
39. The medication charts for Mr J’s time in the care home between May 2017 and June 2018 show he had been prescribed both paracetamol and analgesic gel for use on an ‘as required’ basis. This required care home staff to accurately identify when Mr J was in pain and administer medication accordingly.
40. I note Mr J’s care plans make clear that he had advanced dementia and found it difficult to express himself. In my view, these communication and cognitive difficulties should have led the care home to introduce a pain scoring tool to aid staff in assessing Mr J’s pain. However, I found no evidence in the records to suggest the care home did so until the introduction of the Abbey Pain Scale in June 2018. This is evidence of fault by Care UK.
41. The medication charts for the period between May 2017 and June 2018 show extended periods during which Mr J was given little or no pain relief medication. It is not now possible to identify with any certainty when Mr J was in pain during this period. Nevertheless, I consider it likely, on balance of probabilities, that there were occasions when Mr J was left in unnecessary pain and discomfort. This was a result of the care home’s failure to accurately assess and record Mr J’s pain during this period. This also caused Mrs D further unnecessary distress.
42. In June 2018, as a result of Mrs D raising concerns, the care home introduced the Abbey Pain Scale for Mr J. Using this tool, a carer or nurse is required to score the patient against six criteria:

• Vocalisation (such as moaning, crying etc)
• Facial expression (looking tense, grimacing etc)
• Change in body language (fidgeting, rocking, guarding a part of the body etc)
• Behavioural change (increased confusion, reduced appetite etc)
• Physiological change (raised temperature, pulse or blood pressure etc)
• Physical changes (skin tears, pressure sores, arthritis etc)

43. The scores are then totalled to reach a pain score on a scale of ‘no pain’ to ‘severe pain’.
44. I note Mrs D’s concern that the tool was not suitable for Mr J and failed to capture when he was in pain. However, the Abbey Pain Scale is a recognised pain assessment tool for specific use with patients who are unable to verbalise discomfort. In my view, the use of this tool was appropriate for Mr J. I find no fault by Care UK in relation to this point.
45. In June 2018, the care home also arranged for the analgesic gel to be applied three times per day. Mr J’s paracetamol remained on an ‘as required’ basis, however.
46. I have reviewed the pain scale records from the point staff commenced them in June 2018. These show there only very few occasions during this period when staff recorded that Mr J was in pain.
47. However, the quality of these records is poor. On some days, staff recorded comments such as “[Mr J] had no pain when I asked him” or “no pain reported.” This is of concern given the Abbey Pain Scale was introduced precisely because Mr J was unable to verbalise his pain and sometimes struggled to understand what he was being asked. On another occasion, staff recorded that Mr J was not in pain, but also that paracetamol had been administered. It is difficult to see why staff would have administered this ‘as required’ medication If Mr J was not in pain.
48. This represents poor record keeping and is further evidence of fault by Care UK.
49. In her complaint to the Ombudsmen, Mrs D says care home staff similarly failed to consistently administer Mr J’s other medications.
50. The medication charts show Mr J required eye drops to treat his glaucoma (Latanoprost). Mr J also took regular medication to treat his heart disease. These medications included Aspirin (a blood thinning agent) and Atorvastatin (a medication to reduce cholesterol).
51. In my view, the medication charts support Mrs D’s complaint. For example, between 14 May and 10 June 2018, the records show staff did not give Mr J his eye drops on eight occasions because he was asleep. During the same period, there were seven occasions on which Mr J was not given his Atorvastatin medication. I found no evidence to suggest staff returned to administer the medication at a later time. This was fault by Care UK.
52. While it is not now possible to assess the impact of these omissions on Mr J, I recognise they contributed further to Mrs D’s distress.

Stimulation

53. Mrs D said staff left Mr J in his room alone for long periods of time and did not include him in the activities within the care home. Mrs D said she repeatedly asked staff to get Mr J out of bed in preparation for family visits so they could take him to a coffee shop but that this was rarely done. Mrs D said she also asked for Mr J to be included in activities within the home but that this did not happen either. She said no effort was made to bring stimulation (such as music) to his room.
54. In its response to the complaint, Care UK said the “records do not reflect the actual provision of activities” and that it could not prove or disprove Mrs D’s complaint.
55. In response to my enquiries, Care UK said it only had a full lifestyle team in place at the care home between December 2017 and February 2018. Care UK said that, during this period, staff did spend time with Mr J. However, Care UK acknowledged that it was unable to say what happened during the rest of Mr J’s time in the care home.
56. Mr J’s care plans record that he should be included in activities within the care home and that staff should “[e]ncourage active communication” with him at all levels.
57. I have reviewed the daily care records for the duration of Mr J’s time in the care home. The first substantive entry by the meaningful lifestyle team in June 2017 noted that Mr J “enjoys visits from his family and friends, but he is not overly keen on integrated socialising.” The same entry noted that Mr J enjoyed listening to his radio.
58. A further entry in July 2017 noted “[Mr J] is encouraged where possible to be involved in activities around the home”. This was reiterated in entries in August and September 2017.
59. Indeed, I found no further entries from the meaningful lifestyle team in the records until November 2017, at which point it was again recorded that Mr J enjoyed listening to his radio.
60. In December 2017, it was noted that Mr J “does like to attend some of the activities in the home particularly if there is a singer or choir.” This suggests staff were involving Mr J in activities at this stage, albeit no record appears to have been kept of Mr J’s participation in specific activities.
61. Between December 2017 and February 2018, there is evidence of increased input from the meaningful lifestyle team. This seems to correspond with the period during which Care UK said the team was at full complement. This input largely consisted of staff visiting Mr J’s room to make conversation.
62. In April 2018, staff recorded that Mr J enjoyed listening to a music selection his family had made for him and also enjoyed watching television. A further entry that month noted a conversation between Mr J and a member of staff. From this point until Mr J’s transfer in August 2018, there is very little information in the records relating to his lifestyle.
63. The available records suggest that, between May 2017 and February 2018, care home staff were attempting to engage Mr J in activities and sometimes visited him in his room, albeit records are inconsistent for this period.
64. However, from late April 2018, the records are lacking in any meaningful detail about Mr J’s lifestyle. I found no evidence to suggest staff were attempting to involve Mr J in activities within the care home during this period. Similarly, there is no evidence to suggest staff were visiting Mr J regularly to engage him in conversation or provide other stimulation. This is fault by Care UK.
65. This caused Mrs D uncertainty as to whether the care home was meeting Mr J’s lifestyle needs during this period.

Nutritional care

66. Mrs D complained that the care home continuously failed to provide food that was prepared to the necessary consistency for Mr J. Mrs D said she often had to mash Mr J’s food herself and that it was often so hard that mashing was not possible. In addition, Mrs D said care home staff continued to give Mr J food he did not like. Furthermore, Mrs D said staff did not take the required time to assist Mr J to eat.
67. Care UK apologised if Mrs D felt food had been unsuitable for Mr J. Care UK said the care home was keen to maintain a normal diet for Mr J as far as this was possible but had moved to a pureed diet at Mrs D’s request. The care home said staff assisted Mr J to eat whenever he was not being supported to do so by his family.
68. Section 14(1) of the Guidance accompanying the Care Regulations states that any assessment of a service user’s care needs “should include risks related to people’s nutritional and hydration needs.” The Guidance emphasises the importance of accurate nutritional assessment in ensuring that a service user is provided with an appropriate diet.
69. The records show staff carried out regular malnutrition screening assessments for Mr J during between May 2017 and August 2018. These generally found him to be at low risk of malnutrition.
70. However, Mr J’s care plans contradict this, noting that he “is at high risk of suffering from malnutrition, medium risk of choking.”
71. This is evidence of further poor record keeping and represents fault by Care UK.
72. Nevertheless, the care plans appear to show that care home staff were aware of Mr J’s specific nutritional needs. The care plans record that Mr J required a soft diet (a diet involving soft and moist foods that can be mashed with a fork). This remained the case until July 2018, when it was noted that Mrs D preferred Mr J to have pureed food. In addition, the care plans listed Mr J’s food preferences. The care plans also noted that Mr J needed assistance from staff to eat and drink.
73. I note Mrs D’s concerns regarding the consistency of food offered to Mr J and what she considers to be a lack of support from staff in assisting him to eat.
74. The daily care records note that Mr J’s family assisted him to eat on occasion and sometimes brought food from home for him to enjoy. However, there is little recorded in terms of the level of support offered by staff when family were absent.
75. Similarly, there are no detailed records that would allow me to establish the quality or consistency of the meals Mr J was offered during his time in the care home.
76. In the absence of any additional evidence, I am unable to reach a robust view on these issues.
77. However, the food and fluid balance charts for Mr J suggest he generally ate well during his time in the care home (although he declined some meals). I also note that Mr J’s weight remained steady throughout this period and that, at the time of his transfer in August 2018, he had gained some weight.
78. In my view, the available evidence suggests there were no significant omissions in the nutritional care provided to Mr J during his time in the care home. I found no fault by Care UK in this matter.

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Agreed actions

79. The Ombudsmen found fault by Care UK with regards to the care and treatment provided to Mr J while he was resident in the care home between May 2017 and August 2018.
80. Within one month of this final decision statement, Care UK will take the following actions to remedy the injustice caused to Mrs D by the fault I have identified:

• Care UK will write to Mrs D to apologise for its failure, between May 2017 and August 2018, to provide Mr J with care and treatment that was in line with the Care Regulations.
• Care UK will also pay Mrs D £600 in recognition of the impact this fault had on her in terms of distress and uncertainty.

81. Within three months of this final decision statement, Care UK will write to the Ombudsmen to explain what action it will take to:

• Ensure the care home has robust procedures in place for providing care to service users with dementia or who are otherwise unable to clearly verbalise their needs. These procedures should be compliant with the Care Regulations and provide clear guidance for staff on how to assess and record service users’ needs and how these will be met.
• Ensure the care home has robust nutritional and hydration care policies and procedures in place. These should make clear the importance of accurately identifying and recording a service user’s risk of malnutrition and their specific dietary requirements.
• Ensure the care home has appropriate medication administration policies and procedures in place. These should provide clear guidance for staff on what to do if they are unable to administer a service user’s medication for any reason.
• Ensure service users are supported to engage in activities within the care home and are provided with the necessary stimulation when this is not possible.
• Ensure service users’ dignity and privacy are given appropriate consideration in keeping with the Care Regulations.
• Ensure there is a robust and ongoing audit process in place to monitor the quality of record keeping in the care home. This should include a clear process for addressing omissions in the care records and identifying any staff training needs.

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Final decision

82. I found fault by Care UK in respect of the care it provided to Mr J when he was a resident in the care home between May 2017 and August 2018.
83. In my view, the actions Care UK has agreed to undertake represent a reasonable and proportionate remedy for the impact of these failings on Mrs D.
84. I have now completed my investigation on this basis.

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Parts of the complaint that I did not investigate

85. Mrs D says that Mr J suffered numerous Transient Ischaemic Attacks (TIAs – also known as mini strokes) during his time in the care home. Mrs D complained that staff failed to record these and did not take appropriate clinical observations when they occurred.
86. I note Mrs D’s concerns. However, I have not included this issue within the scope of my investigation. This is because there is no evidence within the contemporaneous clinical records that would enable me to reach a robust decision on whether there was fault in the care provided to Mr J in this area.

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Investigator's decision on behalf of the Ombudsman