Summary: Mrs X complained the Care Provider included incorrect details on her father in law, Mr Y’s care plan, and failed to address her complaint about this and other concerns she raised. She said this put her and her family to unnecessary time and trouble and caused confusion and distress. The Care Provider was not at fault in its management of Mr Y’s care.

The complaint

1. Mrs X complained the Care Provider incorrectly competed care plan records when her father in law, Mr Y, was admitted to hospital.
2. She also complained the Care Provider failed to address her complaint when she raised concerns about its record keeping.
3. Mrs X said this put her and her family to unnecessary time and trouble.

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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. 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 made enquiries and considered the Care Provider’s submission, which included correspondence shared between Mrs X and the Care Provider, the staff rota and Mr Y’s care records and meal chart.
7. I wrote to Mrs X and the Care Provider and considered their comments before I made a final decision.

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What I found

Law

8. 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 never fall.
9. Regulation 17 requires care providers to maintain accurate, complete, and detailed records in respect of each person using the service.
10. Regulation 18 states care providers should deploy enough suitably qualified competent and experienced staff to enable them to meet all other regulatory requirements described in the Health and Social Care Act 2008.

Mrs X’s complaint

11. Mr Y joined the Care Provider’s care home as a self-funded resident several years ago. At the time, the care home was run by a different Care Provider.
12. Mrs X received a call from the Care Provider in mid-September 2019, advising that Mr Y had an infection and would not take his medication.
13. Mrs X says that when she arrived at the care home, there did not seem to be many staff members available, and she was left waiting for a long time. When Mrs X saw Mr Y, she felt he looked ill, dirty, and dishevelled.
14. Mrs X says Mr Y’s carers repeatedly told her Mr Y had not eaten or drank anything all day. Mr Y was taken to the hospital soon after Mrs X arrived to see him. Mrs X says when she saw Mr Y at the hospital later that evening, Mr Y was clean, and he was wearing a fresh pair of clothes.
15. After Mr Y was admitted to a ward, a nurse approached Mrs X to discuss Mr Y’s condition. Mrs X told the nurse Mr Y had not eaten or drank anything all day; however, the nurse said Mr Y’s care plan said he had eaten well that day. The nurse asked Mrs X to confirm whether Mr Y had eaten anything as the hospital could not provide appropriate care without this information.
16. Mrs X contacted the care home at 19.30 to speak to the manager. She was told the manager had gone home but would call her back in an hour and a half. However, Mrs X later received a call from another staff member at 21.45 who repeated that Mr Y did not eat or drink anything that day. When Mrs X questioned why Mr Y’s care plan contradicted this, the staff member could not explain the discrepancy. The hospital opted to treat Mr Y as if he had not eaten anything all day. Mr Y died several days after his hospital admission.
17. Mrs X contacted the Care Provider in October 2019 to complain that the care home was understaffed on the day she visited Mr Y. She referenced Mr Y’s appearance and questioned why she did not receive a call back from the manager when she contacted the care home. She also asked for an explanation for the contradictory information included in Mr Y’s care plan.
18. The Care Provider responded to Mrs X’s complaint in November 2019 and said the care home had been fully staffed on the day Mr Y was admitted to hospital. The Care Provider said staff had tried to change Mr Y, but he had initially resisted this. The Care Provider maintained Mr Y did not eat or drink anything on the day he was admitted to hospital and indicated that the hospital staff not read the notes properly.
19. The Care Provider provided the following notes taken on the day Mr Y was admitted to hospital in support of its response:
• “Breakfast - was offered breakfast but it was declined, not feeling well at the moment.”
• “Lunch - had lunch, shepherd’s pie, veg, fruit flan… ate very little and ate no dessert.”
• “Tea - had tea sandwiches and a bun in their bedroom, ate nothing.”
• “Extras - Had a snack fruit cake, had meal served in their bedroom, ate nothing.”
20. The Care Provider confirmed the manager went home at 20.00 on the day Mrs X called but did not explain why the manager had not called Mrs X to discuss the situation. The Care Provider concluded the letter stating it had provided appropriate care for Mr X. Mrs X brought her complaint to the Ombudsman as she was not satisfied with the Care Provider’s response.
21. In response to our enquiries, the Care Provider confirmed the care home manager was on annual leave the day Mrs X called, and it was the deputy manager who went home at 20.00 that night. The Care Provider did not explain why the deputy manager was not available to speak with Mrs X.

Findings

22. Mrs X says the Care Provider failed to ensure the care home was sufficiently staffed on the day she visited Mr Y. The Care Provider has provided a rota showing five members of staff were on duty on the day Mr Y took ill. The Care Provider typically uses a tool to determine how many staff members are needed to ensure all residents’ needs are met. However, the Care Provider could not confirm whether the home was suitably staffed on this day. This was because it was under different management at the time and so could not confirm how many staff should have been present. I have not received evidence which would allow me to comment or find fault with this part of the complaint and I will not investigate this issue further as there is nothing indicating Mr Y experienced an injustice as a direct result of Mrs X’s concern regarding staffing at the care home.
23. Mrs X complains the care home manager failed to call her back. When she questioned this, the Care Provider did not provide an explanation. It would have been best practice for the deputy manager to call Mrs X back. Further, the Care Provider has not explained why the deputy manager did not speak to Mrs X despite appearing to have been available at the time. Although this may have been frustrating for Mrs X, I cannot see that Mrs X has suffered a significant injustice because of this part of the complaint. She later spoke with a different staff member who confirmed Mr Y had not eaten well that day. It is unlikely Mrs X would have received a different response had she spoken with the deputy manager.
24. Mrs X complains the Care Provider included incorrect information on Mr Y’s care records, which caused confusion and delayed the hospital in providing the correct care for Mr Y. However, the information from the meal charts and from the care home staff was consistent and clear that Mr Y had eaten little or nothing. I cannot comment as to why hospital staff believed Mr Y ate several meals that day, but I cannot hold the care home responsible for these views. In any event, the hospital decided to treat Mr Y as if he had not eaten all day and there is no suggestion his care was compromised as a result. The actions of the hospital are outside our remit.

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Final decision

25. There was no fault in the Care Provider’s actions. I have, therefore, completed the investigation.

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Investigator's decision on behalf of the Ombudsman