Summary: Ms C complained that her mother’s care home said she could no longer stay at the home and did not allow her mother to remain at the home while the family was looking for another home. The Ombudsman found fault, for which the care provider has agreed to apologise.

The complaint

1. The complainant, whom I shall call Ms C, complains to us on behalf of her (late) mother, whom I shall call Ms M. Ms C complains the care home was wrong to say on 6 October 2018, that it could no longer provide the care support her mother needed. Further, the care home should not have:
• Called an ambulance on 14 October 2018 to get her mother admitted into hospital.
• Refused her mother to return to the care home on 15 October 2018, so she could stay at the home while her family was looking for another home.

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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. 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))

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How I considered this complaint

4. I considered the information I received from Ms C and the care provider. I shared a copy of my draft decision statement with Ms C and the care provider and considered any comments I received, before I made my final decision.

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What I found

5. Ms M’s care plan said she had low to moderate care needs overall. She could walk short distances and needed some assistance with personal care. She had low needs with regards to mental ability / health (dementia / cognition / communication).
6. The care home reviewed the care plan every month. Ms M’s daily care notes from August 2018 do not indicate there were any difficulties or challenges with regards to delivering Ms M’s care.
7. Ms M went into hospital in September 2018 with a suspected stroke. She returned to the care home four weeks later on 5 October, with antibiotics for an UTI.
8. The care home says Ms M’s general well-being and mental health had significantly deteriorated while she was in hospital. The care home manager told me he assessed Ms M’s needs in hospital on 5 October. The staff nurse advised Ms M was confused, screaming and at times aggressive. The manager said he approved Ms M’s discharge in the hope that she would settle once she had completed her course of antibiotics. The manager did not want Ms M to remain in the hospital any longer than she should.
9. The needs assessment by the home manager said:
• Can walk 10 meters with supervision of one
• Full assistance needed with bathing, dressing and personal care
• Needs prompting and support at mealtimes
• Not sleeping well at night and restless most of the times
• Short term memory very poor
• Low mood, upset, needs reassurance, seems very confused.
• Nurse said she has been screaming for no reasons and can be aggressive
10. Ms C says her mother had dementia and Alzheimer's. Her hospital stay, and her return to the home, had therefore been very distressing for her mother. Her mother also had an UTI causing confusion. As a result, her mother was very distressed and frightened when she returned from hospital on 5 October 2018.
11. Ms C told me:
• Her mother needed one to one support when she returned to the home on 5 October to reassure her mother and try to settle her again. However, the home did not have the staff numbers to provide this.
• The care home was wrong to tell her on 6 October 2018 that it could no longer provide the care support her mother needed, without giving her sufficient time to settle back first. It is known (and was confirmed by a GP) that people such as her mother need three to four weeks to settle back. However, the home manager dismissed this argument.
12. The care home records show that staff spent a lot of time with Ms M trying to reassure her. When needed, they also stayed with her on a few occasions for several hours, especially during the evening/night. The daily care records between 5 and 9 October 2018 state that:
• First night: Aggressive and rude to staff and residents; throwing things, staff attended to Ms M every 20 minutes to try and calm her down throughout the night
• Day one: Ms M was very confused, regularly asking for help, not eating / drinking a lot, shouting and banging on the table. She refused a wash in the evening. A staff member had to stay with her for two hours at night, because Ms M was banging her bedside constantly while calling for help. Ms M regularly screamed in her sleep. This upset other residents.
• Ms M did not remember the home, thinking she was still in hospital.
• Day two (7 October): Ms M had lunch with family and was confused afterwards needing a lot of reassurance. She started to shout and became angry at staff and a resident. She cried a lot, calling for help. Staff had to reassure Ms M every five minutes. She bit a staff member during medication admission.
• This pattern of behaviour continued during the remaining days.
13. The care provider told me:
• Ms M had been very confused since her discharge. She displayed signs of challenging behaviour and was aggressive to other residents and staff. During these frequent episodes of anxiety, confusion and challenging behaviour, the care home provided one-to-one support, especially during the night.
• Ms M’s behaviour did also not improve after she completed her treatment for an UTI on 7 October. It asked the mental health team for an urgent assessment. However, the team said it first needed a referral from Ms M’s GP, which would take time. There is no supporting evidence of this discussion within the records I have received from the Council.
14. The home manager says: the conversation referred to in paragraph 11 only happened on 9 October 2018, four days after Ms M’s returned to the home. Ms M had poor varying mobility and was double incontinent. She needed help with feeding, and full assistance with personal hygiene. She was screaming very loudly and did not recognise the home, staff or residents. The care home felt that Ms M’s mental and physical support needs had increased significantly, and the home could therefore no longer meet her needs. Ms M’s behaviour was also having a clear negative impact on the wellbeing of other residents, some of which has complained.
15. Ms M’s GP prescribed Lorazepam on 9 October to calm her down. However, the care home said Ms M did not show signs of any improvement, as the medication only worked for short periods. The manager said Ms M’s challenging behaviour proved to be unmanageable.
16. The manager told the family that they would be given time to look for a new care home for Ms M.
17. The GP visited the home on 12 October. The care home record states “GP said we need to speak with her daughter, as we can’t meet her needs, to find possible EMI home”.
18. The manager said the care home also asked the mental health team for urgent support. However, the mental health team said it first needed to receive a referral from Ms M’s GP, which would take time.
19. On 13 October 2018, the day before Ms M went into hospital again, the daily care records state that:
• Ms M tried to get out of bed and screamed for help and banging her frame every 20 minutes during the night. Several residents complained the next morning that her screams were frightening them.
• Ms M screamed and regularly banged her frame in the lounge. She was constantly confused and did not know what was happening.
20. Ms C says that her mother had made a slow recovery and was well enough to go to church with her on 14 October 2018. She returned with her mother to the care home at 4pm. However, the care home called her in the evening to say her mother had collapsed and went into hospital. Ms C says:
• The care home was wrong to call an ambulance to put her mother into hospital again. Staff told her first that her mother had a Panic Attack, but then changed it to a suspected stroke.
• However, the hospital could not find anything wrong with her, and said she was ready to be discharged again the next day.
• The Doctor who assessed her advised that a hospital environment was not good for her mother and she should get back to the care home and familiar surroundings that same day.
21. Ms C believes the care home forced her mother’s re-admission to hospital so it could ‘shift’ the responsibility for her care.
22. The care home records say that, on 14 October 2018, Ms M returned to the home at 4pm. There were no concerns and the home manager told me Ms M was in a bright mood. However, the manager told me Ms M collapsed on a member of staff after dinner. At this point she could not speak, her face was drooped and she looked pale. The observations from staff concluded that she might have had a stroke, and they therefore called an ambulance. The paramedics decided Ms M should go into hospital.
23. The care home manager said the hospital asked the home on 17 October to carry out an assessment of Ms M to determine if she could return to the home. The assessment states that:
• Unable to carry out full assessment due to confusion and challenging / aggressive behavior.
• Two staff needed to cope with challenging behavior to support with bathing, dressing and personal care. Full assistance needed with feeding
• Nurses said Ms M was not sleeping very well.
• Ms M was sad, anxious, aggressive and abusive. No change / improvement in her behavior.
24. The care home manager says that Ms M demonstrated challenging behaviour which, if accepted back to the home, would present a risk to her and other residents. The home would be answerable to the other residents and their families if they got injured by Ms M. The home could therefore not allow Ms M back until her family had found another home. The home was unable to meet her needs and felt it was in her best interest, and the interest of other residents, to transfer from the hospital to a more suitable care environment. As such, the manager told the hospital that the home could not take the responsibility for her care any longer.
25. Ms C says her mother deteriorated in hospital, while the family was trying to find another care home for her. She could no longer do anything for herself, she became incontinent, was no longer eating, immobile, and became clinically depressed.

Assessment

26. The records clearly show that Ms M’s behaviour and needs had significantly deteriorated when she returned to the care home on 5 October 2018. She needed constant attention and reassurance and her behaviour, shouting and aggressiveness was impacting other residents.
27. Ms C says that people such as her mother should have been given three to four weeks to settle back into the home. During this time, the home should have given her mother one to one support for as long as needed. However, such a level of additional support, and the accompanying additional costs, would have gone beyond what the care provider was expected to provide. As such, the care home should have discussed with Ms C if it could be beneficial for her mother to (temporarily) employ an external / agency to provide a one to one care support worker for her mother (if needed on a 24-hour basis), and if Ms C would be willing to pay for these additional costs, which would have likely been in the region of £2,000 a week. This discussion did not take place, which is fault. However, I am unable to conclude if both parties would have agreed that this would be a suitable way forward, if Ms C would have agreed to pay for such an additional expense, and if this would have resulted in a sufficient and sustainable improvement in Ms M’s condition and behaviour.
28. The care home failed to ensure there was sufficient information in its records to explain what happened after Ms C returned to the home on 14 October 2018 at 4pm. This is fault. However, it was ultimately the paramedics who decided that Ms M should be admitted to hospital. I am unable to conclude, on the balance of probabilities, that the home should not have called an ambulance, or that it only did so to shift responsibility for her care to the hospital, as alleged by Ms C.
29. Based on the care home’s assessment on 17 October 2018, the care home concluded for reasons explained in paragraph 24 that Ms M could not return to the home. The care home decided this following an assessment, and it was a decision the home was entitled to make.
30. Overall, there was a lack of sufficient detail in the records with regards to some key events, including: the conversations with Ms C, the discussion with the mental health team and the incident on 14 October 2018. This is fault.

Agreed action

31. I recommended that, within four weeks of my decision, the care provider should:
• Apologise to Ms C for not discussing the option to recruit a one to one carer for her mother, and for its failure to keep a sufficiently detailed record of what happened on the evening of 14 October 2018.
• Ensure that it considers and discusses the option of recruiting a temporary external one to one support worker, in similar future situations.
• Remind (senior) staff of the importance to record sufficient detailed information about discussions with family members and with external bodies, and about incidents.

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Final decision

32. I found there was fault with regards to the actions of the care provider. However, I am unable to conclude these resulted in a different outcome.
33. However, there was no fault by the care provider in the way it reached its decision on 17 October 2018 that Ms M could not return to the home.
34. Under the terms of our Memorandum of Understanding with the Care Quality Commission (CQC), I have shared a copy of my final decision statement with the CQC.

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Investigator's decision on behalf of the Ombudsman