Summary: The care provider failed to offer Mrs A the proper care and treatment while she was resident. It failed to follow its own procedures after she fell. It acknowledged it made inaccurate records. The care provider agrees to apologise to Mr X and make a payment in recognition of the distress its actions caused.

The complaint

1. Mr X (as I shall call the complainant) complains about the care and treatment of his late mother Mrs A in the care home. In particular he complains that the care provider failed to follow its procedures in tending to her after a fall. He says there were failures in essential care for Mrs A, including supporting her to eat and drink. He also says the care provider’s records included observations for Mrs A even after she was hospitalised.

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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))
4. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

5. I considered the information provided by Mr X and the care provider. Both Mr X and the care provider had an opportunity to comment on an earlier draft of this statement before I reached a final decision.

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What I found

Relevant law and guidance

6. 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.
7. Regulation 10 says service users must be treated with dignity and respect.
8. Regulation 12 says care and treatment must be provided in a safe way for service users.
9. Regulation 14 says the nutritional and hydration needs of users must be met. The guidance says, “providers must make sure that people have enough to eat and drink to meet their nutrition and hydration needs and receive the support they need to do so.”
10. Regulation 18 says care providers should notify the CQC of incidents causing serious injury to residents.
11. The care provider’s falls policy says “when a service user has fallen, they will be assessed regarding the nature of the fall and associated consequences, the cause of the fall and the post fall care management needs.”
12. The policy says the person who witnesses the fall or finds the service user after a fall should “not move the service user if there is suspicion or evidence of injury until a full head to toe assessment has been conducted and appropriate action determined by a registered nurse”. The registered nurse should carry out a full assessment, use the proper (2 person) procedures to lift the service user, notify the GP on their next round, monitor every hour for the next four hours, observe for pain or difficulty weight-bearing.

What happened

13. Mrs A was resident in the care home from August 2016, firstly in a residential placement and then, after her fall on 12 August 2018, in a nursing placement until her death in July 2019.
14. Mrs A’s care plan prior to her fall noted she was in good health with low-level mobility needs (able to walk unaided but could be unsteady on her feet). Her nutrition and hydration was a source of concern as she rarely ate more than half her meals. The care plan stipulated the inclusion of fortified and/or high calorie foods in her diet.
15. Mrs A was unable to remember daily tasks and required reminding regularly of simple tasks. The care plan said care workers should work to minimise the risks associated with her daily lifestyle, particularly her habit of walking up and downstairs carrying hot cups of tea.
16. The care home’s records show that Mrs A fell downstairs on 12 August 2018. The care worker who found her called the registered nurse immediately.
17. The nurse who attended Mrs A says Mrs A was lying on her back at the bottom of the stairs. She wrote in her note of the incident that Mrs A’s cup of tea was ‘on top of the 3rd or 4th step’[sic]. She says Mrs A was “alert and orientated” and trying to get up. She says both legs were equal in length and Mrs A said she had no pain in her hips. She says she checked her neck, head and face before moving her into a wheelchair with the aid of one other member of staff and then transferring her back to her room. She says she examined Mrs A in her room and found a skin tear on her arm and bruising on her back, although she was unclear if they were new injuries. She says Mrs A said she was feeling “fine” and so she did not contact the GP “as there was no significant head injuries or deterioration”. Mr X says the nurse’s note suggests Mrs A had fallen the length of the staircase.
18. The care worker who also attended Mrs A noted that Mrs A was ‘assisted up, taken to her room, photos taken of injuries’.
19. The care provider’s records show six overnight checks were made, the last at 07.24, all recording ‘no issues or concerns’. However in the morning Mrs A was found in bed unable to move and taken to hospital by emergency ambulance. For several days while Mrs A was in hospital care workers continued to record night-time observations for her as though she was still at the home (‘resident asleep’, ‘settled night, no issues’ etc). She returned to the home on 23 August to a nursing placement and was no longer able to move independently.
20. Mrs A continued to deteriorate and required the assistance of two carers with personal hygiene and transfers, and assistance with eating and drinking. The care provider’s records show the quantity of food and fluid she consumed decreased significantly. Although the care provider’s records note occasions on which assistance was given with eating and drinking, this was not recorded consistently.

The complaint

21. Mr X complained to the care provider in April 2019. He said he and other visitors had noticed a deterioration in Mrs A’s appearance and cleanliness and so he had requested sight of her care notes. He said there were numerous records that she had thrown food away, thrown it down the toilet or given it to other residents at a time where her weight loss was significant. He expressed concern about the failure to follow proper procedures when she fell in August 2018. He pointed out the recordings which had continued while she was in hospital. He said since her return to the home from hospital care workers had failed to reassure her when she was anxious.
22. Mr X included with his complaint a letter from a family friend who visited Mrs A. The friend said even before Mrs A was admitted to hospital her nails were ‘black with dirt’ and it appeared she had not been washed for some time. She said on occasions Mrs A was wearing dirty clothes, including underwear. She said staff would take away her plate while she was still eating. On occasions staff would put her plate in front of her and expect her to eat unaided although she was lying down. Often the front of her nightclothes was wet with spilled drink.
23. The care provider responded in June 2019. The manager said she had discussed in depth with staff members the need for details and accurate recording. She said she was also looking for relevant training courses for staff. She said she had reviewed all the documentation about Mrs A’s weight, personal hygiene and clothing (but did not say what she had found). In respect of the attention to Mrs A after the fall, she said she ‘felt’ the nurse in charge had followed procedures but said she had reminded her of the need for medical observations and notification of the GP as well. She said the nurse had not notified the CQC or the local safeguarding team as she did not think the accident was serious. She acknowledged that some staff had continued to fill in observations when Mrs A was in hospital. She said three of those staff had since left.
24. In conclusion she said the care provider was willing to offer £650 (the reimbursement of one week’s fees) as a gesture of goodwill.
25. Mrs A died in July 2019.
26. Mr X complained to the Ombudsman about the care and treatment his mother received. He said the care provider had failed to follow its own procedures, had failed to follow the care plan it had drawn up for Mrs A, had not acted on changes in her health properly and had failed to keep proper records.

Analysis

27. The care provider acknowledged it had failed to keep records properly. There were long gaps between recordings of help with feeding and bathing, for example: while they may have been failures of recording and not care, the admitted poor practice of completing notes for an absent resident inevitably increased Mr X’s doubt and anxiety. That was fault which caused significant injustice.
28. The nurse did not adhere strictly to the care provider’s procedures in case of a fall. Mrs A was moved before a head to toe assessment was completed. The nurse failed to notify the GP or to ask for 4 hourly observations. It is insufficient for the care provider to say she followed most of the procedure.
29. There is doubt whether the care provider properly and consistently acted on the alert in Mrs X’s care plan that she was at risk from her habit of walking downstairs carrying a cup of tea, as those were the circumstances in which she was found.
30. There is also concern that Mrs A was not assisted to eat properly, was left in soiled and/or wet bedclothes and was generally unkempt. That was not treating her “with dignity and respect”.
31. The care provider’s response to Mr X’s complaint fell short of a full and comprehensive explanation.

Agreed action

32. Within one month of my final decision, the care provider will provide details of how it has ensured accuracy of record-keeping in its staff since this complaint;
33. Within one month of my final decision, the care provider will explain how it ensures agency nursing staff follow the correct procedures in terms of falls and reporting incidents;
34. Mrs X has sadly died and so no recommendation can help her now. However, Mr A also suffered the anxiety and stress of not knowing whether different treatment after her fall might have resulted in a different outcome for her. Within one month of my final decision therefore the care provider will offer £1000 to Mr X in recognition of that.
35. The care provider will also offer £250 to Mr X to recognise the time and trouble he was put to in making this complaint.

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Final decision

36. Injustice was caused to Mr X by the actions of the care provider. Completion of the recommendations in paragraphs 32-35 above will remedy that injustice.

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Investigator's decision on behalf of the Ombudsman