Summary: There was a failure to seek timely dental care for the late Mrs B and poor communication by the Care Provider about her pain relief. The Care Provider’s complaint response also contained inaccurate information about contact with the GP. This caused Mrs B’s daughter Ms A avoidable distress. The Care Provider will apologise within one month of my final decision.

The complaint

1. Ms A complains about her late mother Mrs B’s care in Southwell Court Care Home (the Care Home) owned and managed by Care Worldwide (Southwell) Ltd (the Care Provider). Ms A complains:
1. There was a failure to seek dental treatment for Mrs B when she was in pain
2. The Care Provider’s complaint response said staff had contacted the GP for pain relief for Mrs B’s swollen mouth but there is no GP record to support this
3. She was not informed Mrs B had been prescribed morphine and staff gave her wrong information about when the GP prescribed the morphine patch
4. Mrs B was pouching food in her mouth and staff failed to contact her GP for advice
5. Food and fluid charts in December 2018 were fabricated to suggest Mrs B’s intake was good, when in fact she had lost weight.
6. A care assistant tried to reuse a mouthcare sponge
7. There was a delay in referring Mrs B to the falls team and the manager told her she had already made a referral to the falls team when she had not.

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What I have investigated

2. I have investigated complaints (a) to (e). My reasons for not investigating complaints (f) and (g) are at the end of this statement.

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The Ombudsman’s role and powers

3. 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)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. We provide a free service, but we must use public money carefully. We may decide not to start or continue with an investigation if we believe the injustice is not significant enough to justify our involvement. (Local Government Act 1974, section 24A(6), 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)

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How I considered this complaint

7. I considered:
• The complaint to us
• The Care Provider’s response to the complaint
• Documents described later in this statement
• Comments and information from the parties on a draft of this statement.

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What I found

Relevant law and guidance

8. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) The Ombudsman considers the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
9. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
10. Regulation 12(i) of the 2014 Regulations says a care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents.
11. Regulation 14 of the 2014 Regulations says the nutrition and hydration needs of residents must be met. They must receive suitable nutritious food and fluid to sustain life and good health, with support to eat and drink if needed.

What happened

12. Mrs B had dementia and lived in the Care Home from 2016 until her death at the end of 2018.
13. The Care Home kept care plans which set out Mrs B’s care needs. She needed help with eating and drinking and had a fortified diet and milkshakes. She used easy grip cutlery and a deep bowl to help her eating. She needed staff to ensure she brushed her teeth.
14. The medication records indicate Mrs B’s GP prescribed a weekly morphine patch on 7 November 2018. There is no record of staff telling Mrs A about this, although the agreed practice was for staff to update Mrs A about any changes in Mrs B’s care and health.
15. The Care Home weighed Mrs B every month. Her weight was stable at around 58 kilos (a healthy weight for her height) until November when there was a loss of 2 kilos and a further kilo in December. Mrs B was still in a normal healthy weight range at the beginning of December.
16. Because of the small weight loss, the Care Home started recording Mrs B’s food and fluid intake on charts in December. Her fluid intake was often poor and on occasion was less than 500 ml a day. Staff also kept food charts recording a poor intake in December. Mrs B often refused food or only ate a very small portion.
17. On 10 December, Mrs B saw her GP as she had been off colour and not eating and drinking. The GP was not sure what was wrong and asked staff to monitor her. The records indicate staff spoke to Ms A after the GP’s visit and updated her. The Care Provider told me the GP felt the morphine patch would provide adequate relief for any pain.
18. Ms A said in her complaint to the Care Provider that she spoke to staff at the Care Home on 17 December and was told Mrs B’s face was swollen and she was in pain. Mrs A said staff had told her that there was no dentist that would come out to the home. Ms A said in her complaint to the Care Provider that she contacted the Clinical Commissioning Group (CCG) on 17 December and the CCG advised her about the home visiting dental service. Ms A then spoke to senior staff at the Care Home, who referred Mrs B to the home dental service.
19. On 19 December, the dentist visited and prescribed antibiotics for an infected tooth. Staff spoke to Ms A and informed her.
20. Mrs B’s health declined and she received end of life care from the district nurses. She died at the end of December.
21. Ms A complained to the Care Provider about the issues she raises with us. It did not uphold her complaints. Its complaint response said Mrs B’s GP prescribed the morphine patch on 10 December. The response also referred to staff having consulted Mrs B’s GP about her dental pain and the GP refused to come out.
22. Information from the GP practice indicates that there was no record of the Care Home contacting the surgery about pain relief for Mrs B’s dental pain.
23. The Care Home’s deputy manager told me the statement in the complaint response about the GP refusing to come out was ‘a misunderstanding’ and no-one from the home contacted the surgery about pain relief for dental pain. The deputy manager also told me she had sought telephone advice from another dentist (which had not registered Mrs B as a patient, but had previously seen her as part of a pilot home visiting service) and was told to use a mouth wash, which was then started straight away and seemed to reduce the swelling. The deputy manager told me she made no record of the discussion with the dentist.

Findings

(a)There was a failure to seek dental treatment for Mrs B when she was in pain

24. I uphold this complaint. The evidence indicates Ms A had to find out about the visiting dental service through contacting the CCG and ask the Care Home to refer her mother. The Care Provider should have known about local health provision and made a prompt referral without Ms A needing to do research. The Care Provider failed to ensure Mrs B had appropriate health care in a timely manner. It did not act in line with Regulation 12(1) of the 2014 Regulations.

(b)The Care Provider’s complaint response said staff had contacted the GP for pain relief (for Mrs B’s swollen mouth) but there is no GP record to support this

25. The deputy manager told me there was no contact with the GP about pain relief for the swollen mouth and the GP surgery has no record of contact. This means the Care Provider’s complaint response contained inaccurate information and so I uphold this complaint. Providing inaccurate information caused Ms A avoidable distress.

(c)Ms A was not informed Mrs B had been prescribed morphine and staff gave her wrong information about when the GP prescribed the morphine patch

26. I uphold this complaint. There is no record of staff telling Ms A about the patch and the Care Provider’s complaint response gave the wrong date. Communication with Mrs A about her mother’s care was inadequate and not in line with what had been agreed. This caused avoidable distress.

(d) Mrs B was pouching food in her mouth and staff failed to contact her GP for advice

27. I have seen no record that Mrs B was pouching food in her mouth. Mrs B lost a small amount of weight from November and staff started monitoring her food and fluid. This was an appropriate response. I am satisfied care was in line with Regulations 9, 12(1) and 14. I do not uphold this complaint.

(e)Food and fluid charts in December 2018 were fabricated to suggest Mrs B’s intake was good, when in fact she had lost weight.

28. There is no evidence charts were fabricated. They record a poor food and fluid intake generally. I do not uphold this complaint.

Agreed action

29. I have upheld the complaints about failing to seek timely dental care, about providing misleading information to Ms A and about poor communication around the morphine patch. The failings in Mrs B’s care caused Ms A avoidable distress. To remedy the injustice, the Care Provider will apologise within a month of my final decision. I will require evidence it has done so.

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Final decision

30. There was a failure to seek timely dental care for the late Mrs B and poor communication by the Care Provider about her pain relief. The Care Provider’s complaint response also contained inaccurate information about contact with the GP. This caused Mrs B’s daughter Ms A avoidable distress. The Care Provider will apologise within one month of my final decision.
31. I have completed the investigation and sent a copy of this statement to the Care Quality Commission in line with our information sharing agreement.

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Parts of the complaint that I did not investigate

32. I did not investigate complaints (f) or (g) because there is no significant injustice. The dates of the referral to the falls team are unclear, but the delay was less than a week. Reusing a mouth sponge would not have caused any harm.

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Investigator's decision on behalf of the Ombudsman