Summary: Mrs X complains about the care provided to Mrs Y and the way the Care Provider dealt with her complaint about that. The Ombudsman finds the Care Provider caused injustice in the way it dealt with Mrs X’s complaints as it falsified records and was not open about the events. He also finds the Care Provider did not adequately care for Mrs Y. He recommends the Care Provider apologise and provide training to all staff about the importance of accurate records.

The complaint

2. The complainant, whom I shall refer to as Mrs X, complains that the Care Provider:
• Did not adequately care for her mother, Mrs Y.
• Did not deal with her complaint adequately.
3. Mrs X says Mrs Y was admitted to hospital severely dehydrated and non-responsive. Also, that when she went to collect Mrs Y’s belongings, staff avoided her and would not let her see Mrs Y’s records in full. This was upsetting because she felt she had a good relationship with the staff.

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The Ombudsman’s role and powers

4. 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)
5. 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)
6. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

7. (Local Government Act 1974, section 26A(2), as amended). In this case, Mrs X is Mrs Y’s daughter and we consider her a suitable person to bring this complaint on Mrs Y’s behalf.
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 considered information from the Complainant and from the Council.
10. I sent both parties a copy of my draft decision for comment and took account of the comments I received in response.

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What I found

Background

The Care Quality Commission

11. 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 fundamental care standards and prosecute offences.
12. Regulation 17 is about good governance. 17(2)(c) says care providers should “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided”.
13. Regulation 20 is about a duty of candour. 20(1) says “Registered persons must act in an open and transparent way with relevant persons in relation to care and treatment provided to service users in carrying on a regulated activity”. The CQC’s guidance on this regulation says:
• Providers must promote a culture that encourages candour, openness and honesty at all levels. This should be an integral part of a culture of safety that supports organisational and personal learning. There should also be a commitment to being open and transparent at board level or its equivalent, such as a governing body.
• Providers should have policies and procedures in place to support a culture of openness and transparency, and ensure that all staff follow them.
• Providers should make all reasonable efforts to ensure that staff operating at all levels within the organisation operate within a culture of openness and transparency, understand their individual responsibilities in relation to the duty of candour, and are supported to be open and honest with patients and apologise when things go wrong.

What happened

14. Mrs Y had lived at Beverley Court Residential Home, run by Hestoncourt Limited (the Care Provider), for over two and a half years.
15. Records provided to me by the Care Provider show that, one morning, just after Christmas 2018, staff found Mrs Y was “clammy” and coughing up phlegm. They called the GP who visited at 11:30 that morning and heard “slight crackles” on Mrs Y’s chest; he prescribed antibiotics. Staff helped Mrs Y to get dressed and telephoned Mrs X late that afternoon to advise the GP had visited.
16. The records note Mrs Y sat in the lounge and was sleepy most of the morning. Staff could not get her to eat or drink at breakfast time so continued to offer until, by late morning, she had eaten some cereal and drunk some juice and coffee. Mrs Y refused lunch but had some milky tea. Mrs Y slept in the afternoon and woke for some drink, but staff stopped as Mrs Y was spitting. Records show staff helped her to bed at 4:30pm as she was sleepy and leaning over however, this time was overwritten as were other times on this day. Mrs Y later ate two mouthfuls of yoghurt and had some tea. She refused further fluids during the night.
17. Mrs Y had a settled night. She ate a few mouthfuls of porridge and had some milky coffee in the morning. Staff helped her up just after 10am, then back to bed after lunch so they could help her to eat in a better position. She ate a small amount of lunch and pudding with some tea. Staff monitored Mrs Y throughout the afternoon, offering fluids at 2pm, 2:30pm, 3:20pm and 4pm but declined. At 4:30, staff offered another drink, but Mrs Y was hot and her breathing quite laboured. At 4:35, staff called for an ambulance which arrived 15 minutes later. The ambulance crew took Mrs Y to hospital where she was admitted. Staff telephoned Mrs X at 4:47pm and advised her that Mrs Y was non-responsive, and they had called for an ambulance. Mrs X called back to ask if she should come to the home; she says staff told her to go straight to the hospital resuscitation ward. However, Mrs X says when she passed the home at 17:10, the ambulance was only just leaving, and she followed it to hospital. The Care Provider’s letter to me states Mrs Y was non-responsive when staff called for an ambulance.
18. Mrs X says when she arrived at hospital, she was told Mrs Y was severely dehydrated. Sadly, she died a few days later. I saw no evidence that either the ambulance crew or the hospital staff raised safeguarding concerns about Mrs Y’s condition.
19. The following day, Mrs X went to the home with her daughter to get some of Mrs Y’s belongings. She says staff almost avoided them and no one offered condolences although she had previously had a good relationship with all the staff. Mrs X asked to see Mrs Y’s file and the Manager brought it for her and read out some papers. Mrs X took some photos of the records. She says, after a few minutes, the Manager was called away and took the file. Mrs X says the manager told her she should leave. The Care Provider says they had a lengthy discussion and a resident became very unwell suddenly. It says the Manager left some documentation with Mrs X and said she would be back but when she returned Mrs X had left. She had returned the documentation to another member of staff. The Care Provider says it believed this had resolved the issues for Mrs X and so did not contact her.
20. Mrs X complained and asked for copies of the original documents for the three days leading up to Mr Y’s admission to hospital. The Care Provider sent a compilation of extracts from the documents and offered a meeting. Mrs X said she did not want to meet but wanted the copies as requested. When she eventually got the copies, she found discrepancies with the documents she had photographed.
21. In May 2019, the Care Provider apologised for the time it had taken to provide the information requested. It said what had come out of Mrs X’s letter was that the Care Provider needed to:
• “look at the way it deals with situations” as it has to “protect confidentiality of other clients while still upholding transparency”.
• Look at “whether families want to come in after the death of a loved one for a meeting to discuss what happened”.
• Look at sending condolences in a card form so that families are aware they were thinking about them.
22. The Care Provider says it has written new guidelines for end of life care. It will now, following the death of a resident, send a bereavement card to the family offering the opportunity of a meeting to help with the bereavement process.
23. The Care Provider’s records show appropriate involvement of professionals and personalised care plans based on risk assessments. The care plans show many changes in response to Mrs Y’s changing needs.
24. The Care Provider had begun working with the local council to arrange a more suitable home for Mrs Y as it felt it could no longer meet her needs.
25. It came to my attention during my investigation, there were more than one version of the care chart for the afternoon of Mrs Y’s admission to hospital. The original version says staff called 999 at 3.35pm, the other says 4.35pm. The original version describes Mrs Y as “sleepy” between 4:30 and 5pm and notes a 5pm check. Both versions show half hourly checks. The second version does not include the 5pm check and describes Mrs Y as “quite chatty and responsive up until 4:30pm”. It also includes a note that Mrs X was called which is not on the original. The care chart from the previous day shows two hourly checks but I saw no need for increased checks noted in the care plans.

Did the Care Provider’s actions cause injustice?

26. Mrs Y was unwell and the Care Provider called the GP appropriately. I found the care planning was adequate and found no reason for concern about how Mrs Y came to be so unwell that she needed hospital treatment. It is not unusual for people in Mrs Y’s situation to become dehydrated. The Care Provider appears to have offered fluids regularly as planned.
27. However, it appears Mrs Y may not have been checked as regularly as the records suggest. The amended documentation is concerning and puts in question all the records for Mrs Y. I cannot be confident that the Care Provider’s records are accurate. This is a potential breach of regulations 17 and 20. I will therefore share a copy of this decision with the CQC. Therefore, I find, on balance of probability, the Care Provider did not adequately care for Mrs Y, although it may only be the care in the last few days that is in question.
28. As the records were amended following her complaint, I view this as an inappropriate response to the complaint and evidence of poor complaint handling. I found the way the Care Provider dealt with Mrs X concerning and this caused her undue stress and anxiety.

Agreed action

29. To remedy the injustice identified above, the Care Provider should:
• Apologise to Mrs X for the injustice it caused.
• Ensure all staff are aware of the need to maintain an accurate, complete and contemporaneous record, for each resident and the serious implications of falsifying records.
• Provide an action plan to the Ombudsman within one month of the final decision showing the action planned to achieve this and progress made.

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Final decision

30. I have completed my investigation and uphold Mrs X’s complaint that the Care Provider:
• Did not adequately care for her mother, Mrs Y.
• Did not deal with her complaint adequately.
31. When the Care Provider completes the agreed actions, it will put right the injustice it caused as far as possible.

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Investigator's decision on behalf of the Ombudsman