Summary: We do not uphold most of Ms A’s complaints about the late Mrs B’s care in a care home because her care was in line with personalised care plans. However, there was a failure to give a full explanation of what happened on the day Mrs B died and this caused Ms A, her daughter, avoidable distress. To remedy the injustice, the Care Provider will apologise within one month.

The complaint

1. Ms A complains about her late mother’s Mrs B’s care in Kingston Nursing Home in Kingston-upon-Thames (the Care Home). The Care Home is owned and managed by Alliance Care (Dale Homes Ltd) (the Care Provider). The Care Provider also trades under the name Brighterkind and is part of Four Seasons Health Care Ltd.
2. Ms A complains:
1. A carer was rude to her and her mother about her mother’s meal choice
2. There was a failure to take her mother’s temperature when her mother had a urine infection
3. Wound care was inadequate
4. There was no explanation about what happened on the day her mother died.
3. Ms A says her mother was anxious about joining in with activities in the Care Home after the incident when a carer was rude and this led to a decline in her health and wellbeing. Ms A also says she had to take time off work to ensure the correct meal was brought to her mother and this resulted in a loss of earnings.

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The Ombudsman’s role and powers

4. 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. (Local Government Act 1974, sections 34B and 34C)
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)

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How I considered this complaint

6. I considered Ms A’s complaint to the Ombudsman, the Care Provider’s response to the complaint and documents described in this statement. The parties received a draft of this statement and I took their comments into account.

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What I found

Relevant law and guidance

7. 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.
8. 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.

What happened

9. Mrs B was a self funder (she arranged and paid for her care privately) and lived in the Care Home until her death in June 2019.
10. The Care Home kept full records of wound care for Mrs B. She had ulcers on her leg. The ulcers were photographed, graded, assessed, given a detailed description and included instructions about how to care for them, including how to dress them. The records indicate the ulcers improved with treatment and had healed by the middle of August 2018.
11. The Care Home’s care plans noted the activities Mrs B enjoyed including being in the garden and spending time with her daughter. Reviews of the care plans noted Mrs B often refused to join in with daily activities, but enjoyed some of the quizzes and art activities.
12. Mrs B saw the GP on 17 August 2018 for a urine infection and the doctor prescribed antibiotics. The temporary care plan in place while Mrs B had the infection said she was to complete the course of antibiotics and staff were to monitor her urine for any abnormal smell or colour and encourage her to drink fluids.
13. The infection did not resolve and Mrs B saw the GP again on 28 August and a further course of antibiotics was prescribed. Staff recorded her temperature on 1 September (the date is recorded incorrectly as 1 September and should be 31 August) as 36.6 degrees at 10 am, 37 at 2.30 pm and 36.6 at 8 pm. Normal body temperature is 37 degrees. Mrs B went to hospital on 31 August and the urine infection had not resolved. The hospital prescribed a different antibiotic.
14. On the day of Mrs B’s death in June 2019, she was noted to have slept well. The physiotherapist visited Ms A and completed upper and lower body exercises with her. The physiotherapist noted Mrs B became breathless so they stopped doing the exercises. Her breathing became normal again after one to two minutes. Mrs B said she was keen to improve but said she was worried about controlling her anger and staying motivated.
15. A carer noted at 11.20 that Mrs B was listening to music after breakfast and complained of shortness of breath. The carer called the home manager. She was given oxygen but was still saying she could not breathe and so staff called an ambulance. The paramedics arrived at 11.48. A full note of the final entry in the Care Home’s records said:

“taken over in the morning in bed, care staff preparing her to give shower as routine, alert and communicating well, no signs of discomfort, taken to dining area and ate breakfast, she tolerated all medications insulin given, after breakfast assisted back to room on the wheelchair as usual seat she was listening to music, at around 1120 am care staff informed that Mrs B was complaining of shortness of breath then immediately called the home manager, ventilation provided and reassured and she said can’t breathe immediately administered oxygen and emergency ambulance contacted, paramedics arrived at 1148am oxygen sat [saturations] unreadable eventually showed 31%, contacted NOK [next of kin] by the home manager, paramedics arrived at 1148 and treatment given, at around 1224 Mrs B was pronounced and verified by paramedics, contacted Doctor at 14:15hours to inform about the incident and requested to come and confirm but he agreed on the paramedic’s report but he will call the coroner’s office and he agreed for the funeral service to collect the body as pre-arranged by NOK body was taken at around 1830 hours”

16. The Care Provider responded to Ms A’s complaint saying:
• It was sorry for the carer’s behaviour and the incident should not have happened. The carer was moved to a different unit after Ms A asked for this in August 2018.
• Mrs B was already in poor health, she had high blood pressure, diabetes, poor mobility and was partially sighted. She had two strokes previously
• There was nothing untoward about Mrs B’s death. It would not share records unless there was a power of attorney for health and welfare and it had no record indicating Ms A had a health and welfare power of attorney for Mrs B. The paramedics were called on the day Mrs B died. The GP issued the death certificate and raised no concerns.

Findings

A carer was rude to her and her mother about her mother’s meal choice

17. The Care Provider apologised for the incident and moved the carer. This was an appropriate response to the complaint and we would not require any further action of the Care Provider. The Care Provider has already remedied the injustice.
18. Ms A suggests her mother became withdrawn as a result of increased anxiety after the incident with the carers. I cannot attribute this as a fault by the Care Provider. The activities care plans noted Mrs B refused to take part in some activities, but enjoyed others. This indicates Mrs B took part in the activities she was interested in.

There was a failure to take Mrs B’s temperature when she had a urine infection

19. I do not uphold this complaint. The records indicate staff took Mrs B’s temperature three times on the morning she was unwell, in the afternoon and evening after she returned from hospital and it was normal on all three occasions. Her care was in line with the temporary plan of care and in line with Regulation 9 of the 2014 Regulations.

Wound care was inadequate

20. The Care Provider’s care plans set out detailed instructions for the management of Mrs B’s leg ulcers. Staff photographed and charted their progress. Care was in line with Regulation 9 and I do not uphold this complaint.

There was no explanation about what happened on the day her mother died.

21. The Care Provider gave a brief explanation of incidents, but it could have given more detail about exactly what had happened as set out in this statement.
22. Mrs B was in poor health but her death was sudden and not expected. There is nothing in the records I have seen to suggest anything untoward but I consider the Care Provider’s complaint response should have had a more detailed explanation and so the response was inadequate. I note the Care Provider may have been concerned about disclosing Mrs B’s records, but it could have provided a more detailed explanation in writing as I have in this statement. I consider the failure to provide a full explanation caused avoidable distress for Ms A.

Agreed action

23. Within one month, the Care Provider will apologise in writing.

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Final decision

24. I do not uphold most of complaints about the late Mrs B’s care in a care home. Her care was in line with personalised care plans. However, there was a failure to give a full explanation of what happened on the day Mrs B died and this caused Ms A, her daughter, avoidable distress. To remedy the injustice, the Care Provider will apologise within one month
25. I have completed the investigation. I have shared a copy of this statement with the Care Quality Commission in line with our information sharing agreement.

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Investigator's decision on behalf of the Ombudsman