Summary: Ms C complained about various aspects of the residential respite care her (late) mother received. We found there was some fault in the actions of the care provider. It has agreed to apologise for any distress these may have caused Ms M and her family.

The complaint

1. The complainant, whom I shall call Ms C, complains on behalf of her (late) mother, whom I shall call Ms M. Ms C complains about the care her mother received during a respite care break at Frances Court care home in Copthorne. She is unhappy:
• About the way in which the care home managed her mother’s peg (feeding)
• That her mother developed a pressure sore, which staff failed to prevent or notice.
• With the way the care home dealt with a leak in her mother’s en-suite bathroom.
• The way the care home responded, when her mother became ill during the night.
• The staff did not put up a sign in her mother’s bedroom to warn staff her mother should not be given anything to eat or drink by mouth (she was peg-fed). This would have posed a serious risk of choking. This was concerning / distressing to the family.
• The care home failed to provide the supervision her mother needed with washing, which had been identified in her mother’s assessment.
• About the way the Care home investigated her complaint.

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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 we are satisfied with the 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

4. I considered the information Ms C and the care provider provided to me. I shared a copy of my draft decision statement with Ms C and the care provider and considered any comments I received, before I made my final decision.

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What I found

The complaint about peg management:

5. Ms C says the purpose of the respite break was to give the family a well-needed 10 days break from the stresses of caring for Ms M. However, there were ongoing issues throughout her stay that concerned the family, several of which needed family members getting involved. As a result, the family did not get the break from caring they had hoped, planned and ultimately paid for. As such, she wants the home to reimburse the fees. She also wants a financial remedy for the distress the family suffered.
6. Ms M went into the care home on Friday 29 March 2019. She could verbally communicate her needs and had full capacity to make decisions about her care. She received food and liquids through a peg, because she couldn't have food normally.
7. Ms C says:
• The home assured her that staff were trained to manage a resident with a peg.
• The family left clear written instructions about Ms M’s feeding regime.
• The family also gave the manual for her feeding machine / pump. It contained clear instructions what to do if there was a problem with the pump, or if staff had a question, namely: call the 24/7 nurse advise line.
8. Ms C says that, even so, the care home constantly contacted the family to ask for help. She says the care home had repeated problems with setting up her mother’s peg feeding machine / pump correctly, even though it had assured the family during the pre-admission assessment that it could manage this aspect of her care without any problems. This was concerning and distressing to the family.
9. According to the records, there were two incidents:
• The home called Ms C on the first night (30 March) at midnight, because there was a problem with the pump for the PEG.
• The home contacted the family on the evening of 2 April 2019, because the alarm of the machine was going off and it could not be stopped. The home says it could not stop the alarm despite following the instructions Ms C supplied
10. The care home told Ms C that:
• Most staff attended training and the care home already had a resident who was being fed through a peg without any problems. However, there are different type of feeding pumps and regimes.
• Ms M was using a type of pump that was different to the one used by the other resident and the one used in recent training. This was discussed at a meeting the following morning. The notes of that meeting clearly show there was an intention to call the 24/7 helpline to understand why this was happening. However, it is not clear why the staff chose to contact the family on the two occasions, rather than the 24/7 helpline.
• The family checked the pump when they visited and agreed it was faulty. The care home subsequently used a different pump.
• The fluid intake charts, and staff interviews confirm that the home adhered to Ms M’s feeding program, despite further issues with the same pump.
11. There is no evidence in the records that says the family agreed the pump was faulty. Ms C also denies the pump had ever been faulty or that her family said this.

Analysis

12. There were initially two issues / problems with the pump, during the first three days of Ms M’s stay at the home. This resulted in the home contacting Ms C and her family, who needed a break from their role as carers.
13. I am unable to determine to what extent, if any, some of these issues were due to the equipment itself. However, the care provider has acknowledged that instead of contacting the family, the staff should have contacted the 24/7 helpline. This resulted in some distress to Ms C.
14. There is no evidence that the above resulted in Ms M not receiving her food during her stay at the home.

The complaint about the pressure sore

15. Ms C says her mother never had a pressure sore before and had not been at risk of getting one because she was mobile. However, she says her mother developed a pressure sore at the care home, which staff failed to prevent or notice. She says this was concerning / distressing to the family.
16. Ms M’s care plan said she could reposition herself independently in bed and slept on a normal profiling bed and pressure reliving mattress.
17. The care home said that:
• Ms M was at low risk of skin damage.
• The family did not mention this issue as part of their original complaint. They only raised this issue at the meeting in July 2019. The family did also not give any details about the grading of the sore, the date it was first noted or the location of the sore.
• The care home investigated it and concluded there was no evidence to suggest that Ms M had a pressure sore whilst she was at the home.
• Ms M was mobile, had full capacity and was able to let staff know if she had any concerns. The hospital or safeguarding have never contacted the home about this, which the hospital would do if they notice such an issue. There are no documents that show an issue about pressure sores was raised on admission to hospital.
18. The hospital records do not refer to a pressure sore.

Analysis

19. There is no evidence to support Ms C’s statement that her mother had a pressure sore when she left the care home.

The complaint about the bathroom leak

20. Ms M’s en-suite bathroom developed a leak and was leaking into the room downstairs. Ms C says that, as a result:
• Her mother did not have an en-suite toilet facility for 24 hours.
• During the day, her mother had to use the toilet at the end of the corridor, and a commode in her room at night. This was unacceptable because, at times, she had severe bouts of diarrhoea.
• Her mother had to walk a significant distance to the toilet in unfamiliar surroundings. Staff failed to reassure her mother and tell her she could call staff to accompany her to the toilet at the end of the corridor.
• Eventually, her mother moved to another room the following day, following her request to move her mother.
21. The care home said it was sorry and explained to Ms C at the time why it was not possible to solve the problem more quickly. Staff also placed a commode in her room, which Ms M could use if she did not want to walk to the toilet. Ms M may have found using the commode undignified, and the walk to the communal toilet longer. However, staff observed her to be safe and independent when she did walk to the toilet.
22. The record related to this night states: assisted to use the toilet regularly during the night and checked throughout the night, slept well.
23. Ms C says the care home told her on Monday morning that her mother had been moved to another room. However, this was not correct. The care home has explained this was a human error as her mother had indeed not moved yet.

Analysis

24. Under the circumstances, the home dealt with this unexpected unfortunate problem in a timely and appropriate manner. Although there was some inconvenience to Ms M, this was only for 24 hours and outside of the care home’s control.

The home’s response to her mother’s deterioration

25. Ms C says that staff failed to respond in an appropriate and timely manner when her mother became ill during the night of 5 April, and on 6 April 2019.
26. Ms C’s daughter told me that:
• Ms M was clearly unwell when she visited on 6 April. She found that her grandmother was disorientated, very sleepy, coughed more than usual, and the cough sounded if she had fluid on her lungs. As such, she felt her grandmother was showing signs of a possible chest infection, which the staff had failed to recognise / look into until she raised her concern. Staff had not even taken Ms M’s temperature until then. When she asked a staff member about it, the staff member said that: this would explain why Ms M did not have a good night.
• She raised her concerns with the nurse and suggested to take her temperature. Her temperature proved to be very high and the nurse provided Paracetamol. As a result, her grandmother seemed to improve a bit. However, she was still concerned that her grandmother may have an infection.
• The nurses told her it would take a few hours for an out of hours GP to visit and assess Ms M. The care home was reluctant to take Ms M to hospital and called a manager for advice. In the end the family took the decision in the evening, to take Ms M to hospital. In hospital, she was diagnosed with pneumonia and sepsis and died four days later.
27. The care provider said that:
• All staff involved with Ms M’s care reported she was cheerful and chatty on 5 April 2019. Staff did not record any health concerns that day or overnight.
• The night staff did not have any concerns regarding Ms M’s health. The records state that Ms M continued to go to the toilet overnight, independently as well as with a guided hand and slept well in between. Both day and night staff reported that Ms M was steady on her feet, and there was not a lot of input required as she did most things herself.
• The team leader reported that Ms M was well and mobilising to the lounge, on the morning of 6 April. No issues were reported when she received her lunch time medication, and she was reported to be her usual chatty self. The Team Leader did not note any shortness of breath, or any chestiness, or see any symptoms that may have led her to believe Ms M was becoming unwell at this point.
• Ms C’s daughter arrived at 3pm. The first indicator that Ms M was unwell, was when Ms C’s daughter indicated Ms M appeared unwell and asked for staff to take her temperature.
• When staff checked her temperature, it was 39.6C. This was high, but the nurse was not unduly concerned and gave Paracetamol to lower her temperature. The nurse said she provided paracetamol and advised staff to check after one hour if her temperature had decreased. Ms M was observed bubbly with secretions, and she was given Nebulizer as prescribed.
• Ms C’s daughter asked if there was a GP who could visit the home. The nurse confirmed that Ms M was not ill enough to call the ambulance and explained it may take longer than four hours to have a visit from an out of hours GP.
• According to the records, Ms M’s granddaughter subsequently called the hospital to talk to Ms M’s consultant and discuss a possible admission. Ms M left at about 5pm, which was two hours after her granddaughter had arrived.
• Staff would have called the on-call GP if the paracetamol had failed. However, this never happened, because Ms M’s granddaughter decided to admit her to hospital instead. The care home’s investigation did not find there were indicators that Ms M was very unwell other than the raised temperature. Ms M was able to walk to her granddaughter’s car.
• Ms M had capacity to decide whether she wanted to go with her granddaughter to hospital. The nurse was sorry that Ms C’s daughter felt she was resisting for her to take her grandmother.
28. Online information from the NHS states that the early signs of pneumonia in elderly people, and of sepsis, can be hard to spot. The hospital recorded on admissions that:
• She was admitted with a cough and fever. Community Acquired Pneumonia.
• Appeared and reported to be well, appeared alert, no phlegm, gurgling breathing, progressive cancer – for palliative care.

Analysis

29. There is no evidence in the records, that Ms M was showing signs of being unwell during the night or in the morning. As such, there is insufficient evidence to conclude, on the balance of probabilities, that Ms M’s health had deteriorated (long) before 3pm and that the care home should have realised this
30. According to the home’s nurse, Ms M only had a temperature and did not have other symptoms that showed she could have a chest infection. I am unable to determine now what exact symptoms Ms M was showing between 3 and 5pm and/or to what extent her symptoms were such that it was clear she needed urgent medical attention.

‘Nil by mouth’ signage in Ms M’s room

31. Ms C says the home should have put a ‘nil by mouth’ sign in her mother’s room so that all staff, including new or agency ones, would know not to give food or drinks to her. She said that not having this, meant it could be possible that a (new/agency) staff member, may not have known / remembered this. This could have posed a serious risk of choking if a staff member was to offer any food or drink. Her mother was prone to want normal food and could have been influenced by anyone in authority who would offer this. Her mother could therefore not be relied on to refuse food or a cup of tea when offered, as she craved this. This was concerning / distressing to the family. On one occasion they overheard a staff member discussing menu options with her mother and once she was offered tea. However, she did not ask the home at the time to put up such a sign.
32. The care provider told Ms C that:
• It is not usual or best practice, for reasons of privacy and dignity, to place signs related to care etc in bedrooms. This is why the home does not do this.
• There are handover sheets, and all staff were made aware that Ms M was NIL by mouth, including the kitchen.
• Ms M had a choking risk assessment, which indicated that she had a PEG feed and that apart from sips of water she was ‘completely nil by mouth’. Her respite care plan also stated that she was ‘nil by mouth’. All care staff are required to reference these prior to delivering care.
• Ms M also had capacity to let staff know if they had attempted to give her food, that it was not appropriate.

Analysis

33. The care home had sufficient arrangements in place to ensure it followed Ms M’s ‘nil by mouth’ plan. There is no evidence that Ms M received something that was inappropriate; as such there was no actual injustice.

Supervision during washing

34. Ms C says her mother had capacity and did not like to have a shower. If staff would just ask her mother if she already had a shower, her mother would have said ‘yes’. The family told the home that one staff would need to ensure that she was having a wash / bath. However, she says the care home failed to provide this supervision and sufficiently check if she had a wash/shower. The need for this had been identified in her mother’s assessment. As such, her mother did not receive the support she needed to maintain her personal care/hygiene. Ms C does not know if her mother had a shower or was washed during her stay, but she smelt strongly of urine on one occasion.
35. The care assessment said: Ms M needs supervision with washing and dressing by one staff.
36. The care provider has said that
• It checked its records and can confirm Ms M had some showers, but not every day. She was reportedly able to make choices and make simple decisions for her care and daily living.
• Staff said that most days Ms M managed her own care needs. The care notes clearly document the days she was supported and the days she was able to care for herself.
• Staff did not document specifically that she had showered, but were able to recall she was very well-presented and they did not have concerns for her hygiene at any point during her stay.
37. The daily records showed that:
• 30 March: Ms M was independent with getting washed and dressed this morning.
• 31 March 7pm: Ms M remained independent with personal care and mobilising.
• 1 April: No records about it
• 2 April 7 pm: Ms M washed and dressed herself independently today.
• 3 April: Ms M washed and dressed herself this morning
• 4 April: Ms M assisted herself with personal care
• 5 April: Ms M assisted herself with personal care

Analysis

38. The records do not sufficiently evidence how often Ms M had a shower and if she had a wash every morning. This is fault. However, they do indicate that it is likely she had a wash on several occasions. Furthermore, Ms M had capacity to decide if she wanted a wash or shower.

The complaint process

39. Ms C says the care home should have waited with its complaint response until all (three) staff members had returned to work and had been interviewed. The family would have been fine with that as long as they had been told.
40. The care home said that:
• We accept that this would have been ideal. However, the investigator was unable to determine when all staff would be back and Ms C was understandably keen to receive a response.
• Unfortunately, there were three staff members who remained on sick leave who therefore could not be involved in the investigation. This included the Home Manager.
• None of the staff returned in the end.
41. Following my enquiry, the care home tried to contact two of the staff members referred to above. However, they had left the care home in 2019 and did not respond.

Analysis

42. Under the circumstances described above, there was no fault in the care provider’s decision that it should finalise its investigation, rather than wait and see if and when any of the staff members may return.

Was there any injustice?

43. With reference to the above, there was some fault with the way the care home dealt with Ms M’s support. The purpose of the stay at the home was to provide the family with a 10 days break from the stresses of caring for Ms M. However, there were several incidents that happened during Ms M’s stay which in a way impacted negatively on the family being able to fully enjoy their respite break. These were:
• Rather than contacting the 24/7 helpline, the home contacted the family on two occasions to help them solve problems with the equipment. These issues resulted in the family being disturbed.
• Her mother’s toilet breaking down, which resulted in Ms M being without an en-suite bathroom for 24 hours.
44. Furthermore, the toilet issue also had some impact on Ms M, as she was inconvenienced by not being able to use her en-suite bathroom and having to move room. There is no evidence to indicate Ms M suffered a significant injustice as a result of the pump incidents referred to above.
45. The home says it did not charge the full respite fees, which were £1,650 per week, but gave a £210 discount per week. It also used its discretion not to charge Ms M for the full 14 days that both parties agreed on. Instead, it only charged her for 10 days. This resulted in a total discount of £1,240.

Agreed action

46. I recommended that, within four weeks of my decision, the care provider should provide an apology to Ms C for any distress she experienced as a result of the faults identified above.
47. The care provider has told me it has agreed with my recommendation.

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Final decision

48. For reasons explained above, I found there was some fault in the actions of the care provider. I am satisfied with the actions the care provider will carry out to remedy this and have therefore decided to complete my investigation and close the case
49. Under the terms of our Memorandum of Understanding with the Care Quality Commission, I sent it a copy of my final decision statement.

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Investigator's decision on behalf of the Ombudsman