Summary: Ms F complains about the quality of care provided to her late mother at a nursing home funded by the Council. The Ombudsman has found fault causing injustice. The Council has agreed to apologise to Ms F.

The complaint

1. Ms F complains about the quality of care provided to her late mother, Mrs J, at Priory Court Care & Nursing Home in 2019. She says the poor care caused her mother's health and mobility to decline. In particular, Ms F says the care home failed to:
• meet Mrs J’s nutritional and hydration needs
• ensure a blood test was carried out to check Mrs J’s lithium levels. As a result, they rose to toxic levels and Mrs J had to be admitted to hospital
• seek medical advice promptly
• keep her informed about Mrs J’s condition

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. We have powers to investigate adult social care complaints in both Part 3 and Part 3A of the Local Government Act 1974. Part 3 covers complaints where local councils provide services themselves, or arrange or commission care services from social care providers, even if the council charges the person receiving care for the services. We can by law treat the actions of the care provider as if they were the actions of the council in those cases. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
4. If we are satisfied with a council’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)
5. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

6. I spoke to Ms F about her complaint and considered the information she sent and the Council’s response to my enquiries.
7. Ms F and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Fundamental Standards of Care

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. The standards include:
• Person-centred care (Regulation 9): The service user must have care or treatment that is tailored and meets their needs and preferences.
• Safe care and treatment (Regulation 12): Providers must do all that is reasonably practicable to mitigate risks to the service user’s health and safety.
• Food and drink (Regulation 14): Service users must have enough to eat and drink to keep them in good health while they receive care and treatment.

What happened

9. Mrs J had dementia and did not have capacity to decide about her care. She had a history of depression for which she was prescribed lithium. She went into hospital in August 2019 following recurrent falls and increased confusion. The social worker assessed Mrs J as requiring 24-hour residential dementia care and Mrs J moved into Priory Court Nursing Home (the Home) on 10 September 2019, funded by the Council.
10. The Home’s pre-admission assessment says Mrs J was able to walk with a frame and support from carers. She could eat and drink independently though needed prompting. The social worker’s care and support plan said Mrs J needed to maintain a nutritious diet due to her lithium medication. There is no reference to the risks of lithium toxicity or its symptoms, which include agitation and diarrhoea, in the Home’s risk management or care plans.
11. The Home’s daily care records show that during her stay Mrs J often declined personal care and became agitated or aggressive. She was eating and drinking, with fresh water available, but declined breakfasts and did not eat all of her meals. There are references to her having loose bowel movements and diarrhoea. Mrs J fell on 18 September 2019 but was assessed by the nurse as not being in pain. By 26 September there is reference to Mr J using a wheelchair; on that day she had an upset stomach and ate very little over the next few days.
12. The Home’s complaint response to Ms F says Mrs J spent 28 September in bed as she was not feeling very well and had complained of pain in her mouth. The Home says the nurse checked Mrs J’s mouth, there was no sign of oral thrush but she would refer Mrs J for a GP visit. The daily records say Mrs J’s granddaughter was concerned Mrs J had a sore mouth and the nurse noted she was not eating well. The nurse tried to contact the out of hours GP but the line was engaged. The record says "She is for GP tomorrow" but there was no GP visit the next day.
13. There is a discrepancy in the records on 29 September. The nurse has recorded Mrs J was eating and drinking well, but the carer recorded she was concerned about Mrs J as she had been in bed asleep all day and was not eating. The Home says it chased the GP who said he would visit on the next round, but I have seen no evidence of this conversation in the records.
14. The daily record says Mrs J was very agitated and not mobilising well on the morning of 30 September; she again ate very little. The nurse has not recorded any concerns and there is no evidence the GP visit was chased up. The next day Mrs J complained of back pain and was lethargic. The nursing care record says, “on GP list to come but he did not visit, pls refer tomorrow”.
15. On 2 October the social worker visited to review Mrs J. Ms F says the social worker was concerned about Mrs J’s deterioration. The updated care and support assessment says the family asked for arrangements to be made so that Mrs J could return home due to their concerns about Mrs J’s deterioration and the care by the Home.
16. The social worker asked the Home to refer Mrs J to the GP and to rehab due to her reduced mobility. The Home faxed the GP surgery to request a visit on 2 October. It says it also faxed the rehab team, but I have not seen a record of that. Ms F says when she contacted the rehab team she was told there had been no referral.
17. The surgery’s advanced nurse practitioner called the next day. Due to the family’s concerns the nurse said she would arrange for a blood test and visit the next day to check for oral thrush; pain relief was given for Mrs J’s back pain.
18. On 6 October it was noted Mrs J required a cushion to support her sitting up in bed. The GP visited on Monday 7 October. He did not consider Mrs J had had a stroke and said he would ask for a blood test as this had not yet been done.
19. Ms F took Mrs J home the next day. She says Mrs J could hardly use a fork, was emaciated and barely capable of lifting her head at times. Mrs J’s BMI on 23 September had been 23. There is no weight record from the end of her stay, but the Home’s nutritional risk assessment of 7 October records Mrs J as being extremely thin/emaciated.
20. Mrs J was admitted into hospital on 16 October due to toxic levels of lithium. She sadly passed away in April 2020.

Ms F’s complaint

21. Ms F complained to the Home in November 2019. Its response said:
• Carers could not force Mrs J to get out of bed or walk if she refused
• The social worker had not expressed any concerns about the quality of care
• Mrs J had been seen twice by the GP surgery
• It had shown Ms F the fax sent to the rehab team on 2 October
• It could not now determine if there were instances of the handling belt being used incorrectly
22. The Home accepted that it should have chased up the blood test requested on 3 October and informed Ms F of Mrs J’s fall on 18 September. It apologised for this.
23. Ms F complained to the Ombudsman in December 2019. The length of our investigation was affected by the coronavirus pandemic.

My findings

24. I have reviewed the Home’s records from Mrs J’s stay, including the daily care records, nursing care records, contacts with the GP and food charts.
25. If a person refuses food, I would expect the home to keep records of food and fluid intake, inform the family, and refer to the GP. Carers should continue to offer food and offer alternative snacks or foods with high nutrient value. The CQC's fundamental standards say care providers must follow people's consent wishes if they refuse nutrition and hydration, unless a best interest decision has been made under the Mental Capacity Act 2005, and action must be taken without delay to address any concerns.
26. The records show carers continuing to offer Mrs J food and drink, in line with her care plan, and recording what she ate and drank. Carers checked Mrs J regularly, as did the nurses, re-offered personal care after she refused it, and used a wheelchair when she was unable to or did not want to walk. I have seen no evidence of poor care.
27. Ms F says she witnessed the carers manhandle Mrs J but I can make no finding on this. The records refer to Mrs J being transferred with a handling belt, but there is no record of her complaining about pain or of any concerns being raised. I therefore do not have enough evidence to reach a view.
28. However, there was a delay in Mrs J being seen by the GP and in having a blood test. I consider the Home’s actions contributed to this. The initial request for a GP visit was made on 28 September, but I have seen no evidence it was chased up until 2 October. In addition, whilst is was not fault by the Home that the blood test was not arranged by the GP surgery on 3 October, the Home has accepted it should have chased the surgery sooner.
29. It is not clear why the GP did not visit on 1 October. Whilst this is not fault by the Home, I consider the Home should have contacted the GP on 30 September; the family had already requested a GP visit and Mrs J remained poorly, not eating and not able to walk. If they had done so, I consider it likely the GP would have visited that day or the next.
30. I cannot, however, say that the GP would have found lithium toxicity or that Mrs J’s condition would have improved. Nor can I say what the cause of Mrs J’s deterioration was or that her lithium levels were too high whilst in the Home.
31. The Home’s care plans make no reference to the risks of lithium toxicity. This was fault. The social worker’s care and support plan refers to the need to maintain nutrition due to the lithium medication. I consider this should have been taken forward in the Home’s care plans and risk assessments. Whilst I would not expect carers to identify lithium toxicity symptoms, if the risks had been identified in the plans, the nurses may have considered the possibility that Mrs J’s diarrhoea and agitation was being caused by lithium toxicity and referred her for a blood test sooner.
32. I find some of the Home’s actions caused injustice to Mrs J. Whilst I have not found poor care, I have found the care plans were incomplete and there was a failure to chase up the GP visit. This meant Mrs J did not get medical attention as promptly as she should.
33. We cannot now remedy the injustice to Mrs J as she has passed away, but Ms F and the family are left with the uncertainty and distress of whether Mrs J’s condition could have improved sooner.

Agreed action

34. The Council has agreed to apologise to Ms F within a month of my final decision.

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Final decision

35. There was fault by the Council. The actions the Council has agreed to take remedy the injustice caused. I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman