Summary: We uphold a complaint about poor record keeping. We do not uphold a complaint about a failure to do appropriate checks on Mr Y. The failure to keep contemporaneous records meant care was not in line with Regulation 17 of the 2014 Regulations. The Care Provider should apologise for the avoidable distress to Mr Y’s family.

The complaint

1. Ms X complains about Carecall Limited (the Care Provider). She says it did not do enough checks on her father-in-law Mr Y the day he went into hospital. Ms X says another relative found Mr Y unconscious in urine-soaked clothes; staff thought he was asleep when he was in a diabetic coma. Ms X also complains the copy of Mr Y’s care record was altered/added to.
2. Ms X would like the Care Provider to apologise and train staff in how to spot the signs of acute illness.

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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)

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How I considered this complaint

4. I considered information from Ms X, her complaint to us and documents described later in this statement.
5. Ms X and the Care Provider had an opportunity to comment on my draft decision. I considered their comments and additional statements from the Care Provider’s staff before making 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 (the 2014 Regulations) set out the requirements for safety and quality in care provision. We consider the 2014 Regulations when determining complaints about poor standards of care. Regulation 17 of the 2014 Regulations requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.

What happened

7. Mr Y stayed in the Care Provider ‘s nursing home in May 2019. He was thought to have dementia, although this had not been diagnosed. The care plan noted he had diabetes and staff were to help him to choose appropriate low sugar food. He was occasionally incontinent. He had swollen hands and feet due to a long-term heart and kidney problem. Mr Y saw his GP on 31 May regarding the swelling. The GP ordered blood tests to be reviewed after the results. The GP noted Mr Y’s chest was clear and there was no sign of infection, but he had swelling.
8. The Care Provider told me:
• The 24-hour care record was generally filled out as care was provided but at times staff may be called to help with a more urgent task and so the care record may be completed retrospectively.
• Carers were expected to complete records in a timely manner and by the end of their shift at the latest.
9. The Care Provider disclosed the 24-hour care record for Mr Y on 1 June. This has entries from two members of staff, a carer and a senior carer. The record said the carer checked Mr Y at 9.38, 12.50, 13.46 and 16.23. He was asleep on all these checks. At 11.10, the senior carer noted Mr Y sat up and had a bacon sandwich. He was washed, dressed and his top changed. At 17:00 the senior carer noted he informed the nurse on duty Mr Y was sleepy and non-responsive. The paramedics were called and took him to hospital. The care record said Mr Y passed urine as he stood up when being lifted onto a trolley.
10. Nurse S said in a statement that when she ended her early shift on 1 June, Mr Y was conscious and speaking.
11. Nurse T said in a statement that Mr Y’s daughter (Mrs Z) arrived at 15.20 on 1 June. A carer reported to Nurse T that Mrs Z was worried Mr Y was unwell and not responsive. Nurse T said she went to speak with Mr Y and he responded and was conscious. Nurse T said she read Mr Y’s notes and called an ambulance due to Mr Y’s complex medical history. She said Mr Y called out when the paramedics examined him and when she helped the paramedics to transfer Mr Y on to a trolley, he passed urine. She asked the paramedics if she should change him and they said not to due to him needing to get to hospital urgently.
12. The senior carer on duty on 1 June said in an internal interview that he could not find the 24-hour care record for Mr Y on 1 June, so he noted down the care provided in a notebook which he carried with him. The senior carer said he got a new copy of the care record and transferred the information in his notebook into it towards the end of the day. In a second statement for this investigation, the senior denied writing the notes a few days later and said he wrote them on 1 June.
13. Mr X told us she visited the home on 4 June in the evening to collect Mr Y’s belongings as the family had decided he would not be returning there. Ms X told us she did not recall signing the visitors’ book. The visitors’ book did not have Ms X’s name in it as having visited on 4 June. In fact, there are no entries for any visitors connected with Mr Y on 4 June.
14. Ms X told us when she was packing up Mr Y’s belongings, she noticed some of his care records, including the record for 1 June were still in Mr Y’s room. She told us she took a photo of the record. The meta data on the photo indicates it was taken on 4 June at 9 pm.
15. The photo Ms X has provided is different from the record the Care Provider disclosed to me (see paragraph 9). It only has the checks on Mr Y at 9.38, 12.50, 13.46 and 16.23, all in the handwriting of the carer. It does not contain details of Mr Y’s breakfast, personal care or the entry at 17:00 (namely the entries by the senior carer)
16. Ms X met with senior staff of the Care Provider and asked some questions which the Care Provider replied to in writing as a formal complaint response. The Care Provider said:
• Mr Y responded to Nurse T on 1 June and the nurse felt he was choosing not to talk and was able to make facial expressions and was vocal when the paramedics were assessing him.
• He passed urine when the paramedics stood him up.
• The paramedics did not want staff to change him as they thought he may need urgent treatment due to possible sepsis.
17. Ms X was unhappy with the Care Provider’s response and asked us to investigate.
18. The Care Provider’s position is:
• Ms X did not visit to collect Mr Y’s possessions on the evening of 4 June, his daughter, Mrs Z did. A nurse on duty confirmed this in a statement
• The meta data on Ms X’ photo (showing the date and time taken) can easily be altered and Ms X works in the computer industry and so is well placed to know how to do this.
• The photo Ms X provided could have been taken on 1 June by Mrs Y when she visited her father. Mrs Y came in the afternoon and may have taken the photo during her visit and before the senior carer added his entries before the end of his shift.

Findings

19. On a balance of probability, I consider the care record on 1 June was retrospectively completed by the senior carer after 4 June. My reason for reaching this conclusion are that his statement that he could not find the 24-hour care record for 1 June and so started a new record which he completed towards the end of the day cannot be correct. If this were the case, I would not expect the record to have any morning entries from another carer.
20. The Care Provider’s position is that Ms X did not visit the home on 4 June and so did not take the photo. It says Mrs Z, his daughter visited. Ms X maintains she visited and Mrs Z was at the hospital with her dying father. I do not see why Ms X would lie about visiting the home on 4 June or about having taken the photo then and it seems more likely that Mrs Z would be at the hospital with her father, rather than collecting his belongings. It is not in dispute, however, that someone from Mr Y’s family collected his belongings on 4 June. I consider staff on duty on the evening of 4 June should have ensured the visitors’ book was signed by whichever family member visited. And there should also have been a signed inventory of items removed from Mr Y’s room. This is standard practice in the industry.
21. As such, I consider the Care Provider’s record keeping was not in line with its policy or with Regulation 17 of the 2014 Regulations because the 24- hour care record was not contemporaneous, there was no signed visitor record and no inventory of Mr Y’s belongings. So I uphold Ms X’s complaint about record keeping. I consider the Care Provider’s actions caused Ms X and other members of Mr Y’s family avoidable distress and uncertainty about what happened on 1 June.
22. I am satisfied, based on the care records and the statements from the nurses, that staff did appropriate and sufficient checks on Mr Y on 1 June and that he suffered an episode of incontinence in the presence of the paramedics. There is no evidence to suggest he was left wet or was unconscious.

Recommended action

23. I recommend the Care Provider apologises in writing for the failings I have identified within one month of my final decision. It should follow guidance on writing apologies that I will provide when I issue my final decision.

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Final decision

24. I uphold a complaint about poor record keeping. We do not uphold a complaint about a failure to do appropriate checks on Mr Y. The failure to keep contemporaneous records meant care was not in line with Regulation 17 of the 2014 Regulations. The Care Provider should apologise for the avoidable distress to Ms X.
25. I have completed my investigation and will share a copy of my final decision with the CQC in line with our information sharing agreement.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman