Summary: Mr B, complains on behalf of his grandmother, the late Mrs C, about the care provided to her at one of the care provider’s homes. The Ombudsman finds some fault in record keeping. That fault led to uncertainty for Mrs C’s family about the care she had received. The care provider has agreed to provide a formal apology to the family and implement service improvements.

The complaint

1. The complainant, whom I shall call Mr B, complains on behalf of his grandmother, the late Mrs C, about the care provided to her at Hazelmere House by Bupa Care Homes (GL) Limited (‘the care provider’).

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What I have investigated

2. I have investigated those parts of Mr B’s complaint which concern:

• Moving and handling arrangements made for Mrs C in the home, and how the care provider responded to injuries Mrs C sustained; and
• The care she received in the 24-hour period before she was admitted to hospital.

3. The final section of this statement sets out my reasons for not investigating other aspects of this complaint.

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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. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
5. We provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation into a complaint, or part of a complaint, if we believe for example:

• the action has not caused injustice to the person who complained, or
• the injustice is not significant enough to justify our involvement, or
• it is unlikely we could add to any previous investigation by the care provider, or
• it is unlikely further investigation will lead to a different outcome.

(Local Government Act 1974, sections 34B(8) and (9))

6. If the person affected by the matter in the complaint has died, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (section 26A or 34C, Local Government Act 1974)
7. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

8. I considered all the information provided by Mr B about the complaint. I made written enquiries of the care provider and took account of all the information and evidence it provided in response.
9. I have taken account of the Ombudsman’s guidance on remedies.
10. Mr B and the care provider had the opportunity to comment on two drafts of this decision, and I considered all comments received in reply.

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What I found

Fundamental Standards of Care and the Care Quality Commission

11. 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.
12. The standards say the care provider must maintain an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided. Records relating to care and treatment must be complete, legible, indelible, accurate and up to date, with no undue delays in adding and filing information, as far as is reasonable.
13. The CQC is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.

Background

14. Mrs C was a self-funding resident at Hazelmere House (residential and nursing care). She died in August 2019, having been admitted to hospital the day before.

Moving and handling concerns

15. Mr B had concerns that staff may have been too rough when assisting Mrs C and he brought this concern to the attention of the care provider after her death.
16. Responding to this, the provider noted a review of her care plan showed that regular body maps had been completed. These did not indicate any unexplained bruising: the provider confirmed Mrs C had been prone to bruising due to her prescribed medication. The provider also noted that records showed she had sustained friction injury to her left heel and the inside of her knee. Those injuries were healed at the home. The provider confirmed that all staff at the home were trained in moving and handling and no concerns about its practices had been raised with the manager at the home.

What the records show

17. The care provider’s records include information which shows that Mrs C preferred to stay in bed, or in her chair, unless she was attending an activity. She was not mobile, and required staff to change her position every four hours. She had bedrails and bumpers in place. The providers records include relevant documentation such as risk assessments, tissue viability assessment, and care plans. In respect of any injury, there are body maps on file recording various blisters, scratches, and pressure wounds when these arose. Mrs C’s care plan in respect of skin evaluation refers in particular to pressure damage to her left heel, and notes evidence frequent assessment of the wound, redressing etc. On 28 February 2019, the daily care records noted a large bruise to the left knee around a grazed area which was described as longstanding. This was described as resulting from friction from rubbing the knee on the bedrail bumper. Shearing caused by repetitive movement was also noted to be the cause of the sore to Mrs C’s left heel.
18. It is clear that Mrs C was at high risk of pressure sores and similar injury, by virtue of her impaired mobility, and this was clearly reflected in the assessments carried out by the provider and appropriately noted in her records. In addition, the provider has explained that her prescribed medications exacerbated bruising. The provider’s policy in respect of incident reporting and management includes the process for reporting incidents on a specified form. In this case, the relevant incident reporting form was completed on 28 February 2019, noting that Mrs C had a wound to her left knee having knocked off a scab, and old bruising to area was also noted, with the cause attributed to rubbing on the bedrail bumper. Photographs were taken. The injury was noted as ‘a breach of skin integrity’, and minor in severity: a care plan was drawn up and the wound dressed for protection. There is evidence to show that the injury was subject to frequent assessment and redressing. This injury recurred over time despite attempts to cushion the area with a pillow.
19. The evidence submitted by provider shows that relevant records were kept, and protocols correctly followed. In addition, while there is no indication that the injuries described occurred as a result of inappropriate handling, the provider has supplied evidence which shows that that the home achieved full compliance in training for moving and handling of residents, with no staff being overdue this training.

Mrs C’s care in the 24-hour period before admission to hospital

20. Mr B complained that the day before Mrs C died his mother had attended the nurses desk and voiced her concerns to the nurse in charge as to Mrs C’s deterioration in health.
21. Responding to this, the provider said it was evident from its records that the nurse had gone to Mrs C’s room, made observations and had no concerns, and that when interviewed the nurse had said that later in the day Mrs C did not appear her usual self and was complaining of having pain in her stomach. The nurse said paracetamol was given and Mrs C later opened her bowels and informed the nurse she was feeling better. The provider says this information was passed to the nurse on the night shift during handover. In its further response to the complaint the provider said that the nurse had stated that she told Mr B’s mother that they would monitor Mrs C, contact a GP if required, and would keep the family informed.

What the records show

22. The daily care records for 24 August show that at 12.35 hours Mrs C was described as settled and that there were no concerns. There is no further entry in the daily care records for that day. The next entries begin at 04.00 hours on 25 August. They record that Mrs C was ‘clammy’; her blood pressure was taken and noted, and her temperature was recorded at 39.4C. She was given paracetamol.
    The notes then state that she opened her bowel. The out of hours GP service was notified. Further checks were made on her temperature at 04.30 hours, a recording of 39.6C being noted, and at 04.45 it was noted that the out of hours service had booked an ambulance for transport to hospital. The ambulance arrived at 06.10 hours and Mrs C was taken to hospital. She died on 26 August 2019. Records indicate that she had sepsis.
23. There is no record in the daily care notes to reflect the account given by the nurse in charge on 24 August that she had taken Mrs C’s observations, noted the complaint of stomach pain, and administered paracetamol. There is an entry in the medication record which refers to paracetamol being given at 4pm on 24 August, which in isolation would support the nurse’s account. However, the entries in the medication record appear in the following order:

• 23/8/19 17.30 paracetamol solution given to reduce temperature.
• 25/8/19 04.00 paracetamol given due to fever.
• 24/8/19 16:00 paracetamol given as complaining of abdominal pain.

24. The out of sequence recording gives rise to concern about when the record for 24 August was added, and why it appears not to have been made contemporaneously. I am unable to establish whether the events happened as described but were improperly recorded, or did not in fact happen.

Analysis

25. On the first point, regarding Mrs C’s injuries and how they were addressed, on the evidence so far seen and for the reasons set out in paragraphs 17-19 above, I find no fault in the actions of the care provider.
26. On the second point, regarding Mrs C’s care in her last day at the home, on the evidence so far seen and for the reasons set out in paragraphs 22-24 above, I find that there was some fault by the provider.
27. I cannot conclude that this fault, whether solely in record keeping or in failing to administer a dose of paracetamol at 16.00 hours as noted for abdominal pain, led to significant injustice for Mrs C. Observations at lunchtime on 24 August had given no cause for concern, and when she was observed at 04.00 the following morning to be clammy and with a high temperature, action was swiftly and appropriately taken. As the provider noted in its response to Mr B’s complaint, sadly symptoms and signs associated with sepsis usually come about very quickly.
28. However, in addition to the out of sequence recording referred to in paragraph 23 and 24 above, the lack of records of any observations in the daily care notes between 12.35 hours on 24 August and 04:00 on 25 August is inconsistent with the recordings for the previous two days which both show checks on or around midnight (23.35 hours on 22 August and 0.00 hours on 24 August). Overall, the identified inconsistency in record keeping means that that there is a lack of certainty about what care Mrs C was given in the intervening period. That causes distress for Mrs C’s family.

Agreed action

29. In recognition of the injustice identified above, I recommended that within four weeks of the date of the decision on this complaint, the care provider:

• Issues Mr B with a formal written apology for the distress caused to Mrs C’s family by the fault identified in this case; and
• Ensures that all relevant staff are reminded about the importance of thorough and timely record-keeping, and review staff training on the completion of care records.

30. The care provider has agreed to my recommendations.

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Final decision

31. I have completed my investigation on the basis set out above.
32. Under our information sharing agreement, I have shared the decision on this complaint with the CQC.

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Parts of the complaint that I did not investigate

33. Mr B’s complaint included the following:

• That during visits Mrs C was often found with no lights or television on in her room;
• That during a visit she was found in her room in a state of undress; having been left mid-way through her personal care while staff attended to another resident;
• That on visiting, relatives found no towels available in Mrs C’s bathroom, and dirty laundry in the corner of her room; and
• That after Mrs C died the home showed a lack of compassion, and the family did not receive a letter, card of sympathy or a thank you for using the home.

34. For the reasons set out in paragraph 5 I did not investigate these matters. On some points it would not be possible to ascertain the facts around some of the events, and on others the care provider responded appropriately when it dealt with Mr B’s complaint, offering apologies and taking steps to address matters with staff where necessary.

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Investigator's decision on behalf of the Ombudsman