The Ombudsman's final decision:
Summary: Ms X complained about the level of care provided to her mother, Mrs M, whilst she was in a care home. The care provider was at fault for failing to put Mrs M’s name on the list to be seen by a nurse practitioner when Ms X requested this. It has already apologised for this.
- Ms X complains, on behalf of her mother, Mrs M, about the level of care provided by Church Farm House care home between mid April and mid May 2019. In particular she complains the care home:
- Failed to request a GP visit when Ms X requested this;
- Did not put Mrs M on a list to see the visiting nurse practitioner;
- Did not monitor Mrs M’s fluid intake; and
- Failed to ensure a urine sample was provided to the doctor’s surgery to check whether Mrs M had a urinary tract infection (UTI) for three weeks.
The Ombudsman’s role and powers
- 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)
- We normally name care homes in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home. (Local Government Act 1974, section 34H(8), as amended)
- 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)
How I considered this complaint
- I considered:
- the information provided by Ms X;
- the information provided by the care provider, including its records and relevant policies;
- relevant law and guidance, as set out below; and
- our guidance on remedies.
What I found
Fundamental Standards of Care
- 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 not fall. The standards include the right to person-centred care, to be treated with dignity and respect and to receive safe care.
- The standards say the care provider must have a system in place to handle and respond to complaints. They must investigate complaints thoroughly and take action if problems are identified.
- Care providers will usually carry out an assessment of a person’s needs before the person moves into the care home. This enables them to decide whether they can meet the person’s needs. The information about what support the person needs is set out in a care and support plan. This will include, for example, how the care provider will manage the risk of the person falling in the care home, and what support the person may need to ensure they have appropriate food and drink.
- Mrs M’s family decided she needed to live in a care home. The care home assessed her needs in a rehabilitation centre and agreed it could meet them. Its records show it was told Mrs M needed prompting to eat and drink, some support with washing and dressing, suffered from confusion at times and had a history of falls. The rehabilitation centre said there was a history of falls whilst Mrs M had been there.
- Mrs M moved to the care home in mid April. For the first three days she did not want to get out of bed, except to use the toilet. Ms X was concerned and asked the care home to arrange a GP visit. The care home said it would put Mrs M on its list to be seen by the visit nurse practitioner. If the nurse practitioner decided Mrs M needed to see a GP he would arrange this. Ms X asked for the GP visit on a Friday and the nurse practitioner was due to visit the following Tuesday because the Monday was a bank holiday.
- The care home forgot to add Mrs M to the list so the nurse practitioner did not see her on the Tuesday. Ms X called the care home on Wednesday for an update at which point the error was discovered. The care home emailed the doctor’s surgery the same day and asked for a GP visit. The GP saw Mrs M the same day. He reviewed her medication and made some changes to it. He asked the care home to provide a urine sample to check whether Mrs M had a urinary tract infection (UTI).
- A urine sample was provided but the bottle was labelled incorrectly. There is a dispute about whether the care home or doctor’s surgery was responsible for that error. The doctor’s surgery told Ms X it was the care home’s responsibility to label the sample bottle. The care home said the surgery provided sample bottles with a form already completed and that it was the surgery’s responsibility to ensure the correct bottle and paperwork was provided. The error meant the surgery did not get any results. The doctor’s surgery told the care home about the error at the end of April and asked it to obtain a second sample.
- The care home tried to obtain a second sample but Mrs M was unwilling to provide one, even though the care home explained why it was important for her to do so. The care home asked the family to try to persuade Mrs M to provide the sample. Mrs M had not provided the sample by mid May when she was admitted to hospital after a fall. The hospital found she was dehydrated and had a UTI.
- Ms X complained about the level of care provided to her mother. The care home apologised for its mistake in not putting Mrs M on the list to see the nurse practitioner on the Tuesday after the bank holiday but said the nurse practitioner had seen Mrs M every week after she was seen by the GP. It said it had told the GP and nurse practitioner Mrs M was only eating and drinking small amounts on each occasion. It said Mrs M was managing her toileting independently and it could not obtain a urine sample without her consent.
- Ms X said the care home did not ensure Mrs M was properly hydrated and did not monitor her fluid intake. The care home’s policy on hydration said fluid charts would only be used where “a clinical need has been identified”. The care home says it has since changed its policy and will now complete a fluid chart for all new residents in the first week after admission. The records show the care home did offer drinks regularly and encouraged Mrs M to eat and drink. It noted Mrs M was only eating and drinking very small amounts and raised this with the health professionals who were caring for Mrs M.
- Ms X said her mother did not have a history of falls before she went to the care home and she was concerned that Mrs M had a number of falls after moving to the care home. The records show Mrs M was found sitting or lying on the floor on occasion but told staff she had not fallen. The records stated Mrs M said she wanted to be on the floor. Staff checked there were no injuries and that she was not distressed. There were two occasions were Mrs M did fall, including the one that led to her hospital admission. The care home informed Ms X about both of those falls. The care home carried out a falls risk assessment, which identified Mrs M as having a medium risk of falls. Mrs M spent much of the time in bed or in her room but did use the toilet independently. The records show care home staff checked on her every hour.
- Ms X said she wanted all the care fees refunded. The care provider offered to refund 20% of the fees as a goodwill gesture. Ms X did not accept that offer and complained that her mother was not even at the care home for two of the weeks charged for.
- The care home’s terms and conditions state rooms will be reserved for residents who are on holiday or in hospital. The fee is payable in full for the first week of the absence and reduced by 10% after that for long term residents. However, for short term residents the full fee is payable throughout the absence.
- The terms say either side may terminate the contract on 28 days’ notice for long term residents or on seven days’ notice for short stay residents or those within a trial period. Mrs M went into hospital in mid May. On 20 May Ms X told the care home the view of the hospital and social worker was that Mrs M would need nursing care in future. The care home charged Mrs M for the period to 28 May, which is when the hospital confirmed Mrs M needed nursing care. It does not appear to have reduced the fees by 10% after the first week in hospital.
- Before Mrs M went to live in the care home, it carried out an assessment of her needs to make sure it could meet them. It carried out further assessments in the first few days, including assessing her risk of dehydration and falls.
- Ms X asked the care home to arrange for Mrs M to be seen by a GP. The care home failed to put Mrs M on the list for the nurse practitioner. This was fault. This meant Mrs M had to wait another two days before being seen by GP, which was almost a week after Ms X first requested this. There is no evidence her condition deteriorated significantly in the additional two days before a GP saw her, although it did cause Ms X some worry. Therefore, I consider the care home’s apology was a sufficient remedy for any injustice caused.
- The GP reviewed Mrs M’s medication and suggested a urine sample be sent to the surgery to check whether Mrs M had a UTI. The sample bottle was incorrectly labelled. There is a dispute about whose responsibility it was to label the bottle. I cannot resolve this dispute and therefore, I cannot make a finding about the mis-labelling of the sample bottle. I note that this delayed the diagnosing of the UTI but I cannot say this was the care home’s fault in the circumstances.
- The care home was not able to persuade Mrs M to provide another urine sample, despite explaining why it was needed. Mrs M was using the toilet independently so the care home could not obtain a sample without her knowledge or consent. The failure to obtain a sample meant the UTI was not diagnosed until Mrs M went into hospital. However, I cannot say this was due to fault by the care home.
- Mrs M was seen regularly after the initial GP visit. Health professionals did not suggest the care home monitor Mrs M’s fluid intake and its policy did not require it to do so. It was not at fault.
- The care home carried out an assessment of the risk of Mrs M falling. Mrs M stayed in her room, mostly in bed. The care home managed the risk by checking on her every hour, which was appropriate. The care home was not at fault.
- The care home’s terms and conditions say it will charge residents for the first full week of a hospital stay and will reduce the fee by 10% thereafter. It does not appear from the information that it reduced the fee for the second week of Mrs M’s stay (six days between 23 and 28 May). This may be because the care home was treating her as a short term resident because she had been there less than a month, in which case it would be entitled to charge the full fee for the entire period of absence. Even if this was fault it has not caused an injustice because it later agreed to reduce its fees for the entire period by 20% as a goodwill gesture. The care home accepted seven days’ notice to terminate its agreement and did not charge for the last three days in May. It was not fault for the care home to charge fees up to and including 28 May.
- The care home has already apologised for the failure to put Mrs M on the list for the nurse practitioner when Ms X first requested this. It has also offered to reduce its fees by 20% as a goodwill gesture. No further recommendations are appropriate.
- I have completed my investigation. I have found fault leading to personal injustice. The care provider has already offered to remedy the injustice caused so no further recommendations are appropriate.
Investigator's decision on behalf of the Ombudsman