The Ombudsman's final decision:
Summary: We found that Allington Court Care Home failed to maintain appropriate records, failed to properly monitor Mr X’s mother’s food and fluid intake and did not pass on accurate information to another care home. Mr X also complained that Allington Court wrongly influenced decisions taken about his mother’s eligibility for CHC. We found no fault in this respect. We recommended a remedy to recognise that the family were left with some uncertainty about the impact of the fault on their mother.
- Mr X complains that Allington Court care home failed in its duty of care to his late mother, Mrs X, because it:
- Failed to keep full and accurate records about Mrs X.
- Failed to monitor Mrs X’s nutritional intake and weight loss and failed to seek the appropriate intervention when Mrs X lost a significant amount of weight.
- Wrongly influenced decisions regarding NHS funding for Mrs X.
- Incorrectly advised that Mrs X had no nursing needs and forced her to transfer to a residential placement.
- Did not share relevant information about Mrs X with the home she later transferred to a residential care home.
The Ombudsman’s role and powers
- 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)
- 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)
- 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.
How I considered this complaint
- I considered the information Mr X provided. I asked the care provider for information and I considered its response to Mr X’s complaint.
- Mr X and the care provider had an opportunity to comment on my draft decision. I considered their comments before making a final decision.
What I found
- In May 2018 Mrs X was receiving some care at home organised by the Council. However, as her needs were increasing, Mrs X’s family arranged for her to go to Allington Court Care Home for a week of respite care, while they considered the options for meeting her needs in future.
- The manager of Allington Court made a visit to assess Mrs X while she was still at home. He decided the home could meet Mrs X’s need for a respite stay. The manager indicated that Mrs X would need Bupa Band Three care; ‘moderate care needs’. This allows for provision of up to one hour of nursing care per day. Bupa says that Band Three service users’ needs would generally be ‘unstable but predictable’.
- At his home visit the care home manager found medication on the floor and down the side of the sofa. He stated it was clear Mrs X’s partner was unable to care for her and that she needed to receive 24-hour care.
- Mrs X was admitted to Allington Court on 11 May, for a respite period of two weeks, rather than the one week originally being considered.
- Mrs X’s needs were assessed on her admission. The assessment contained some contradictory information about whether Mrs X’s care needs would fall into Bupa Band Four or Bupa Band Three. Both were indicated. A section on stability was not completed. But the assessment form indicated Mrs X’s needs were considered predictable.
- The notes on the assessment stated “poor appetite”, but the section on weight, recent weight loss, and assistance with eating and drinking was left blank. A summary of what Mrs X’s normal day should look like recorded “Soft diet taken, eats independently”, with the associated risk being “weight loss”.
- A moving and handling assessment from 11 May recorded Mrs X’s weight as 60.4kg on admission.
- An undated entry to Mrs X’s care and support plan stated “[Mrs X] can eat independently she needs reminder and prompting to sit and finish meals.” What seem to be separate, undated additions state:
“[Mrs X] needs lots of support and reassurance to eat and drink, she can spit her food out on to the plate”; and;
“Mrs X may need support to eat and drink, she has recently lost weight”.
- A Malnutrition Universal Screening Tool (MUST) was started. It too was undated. It records Mrs X’s weight on admission on 11 May but it was not updated further.
- An assessment of wound care on 15 May noted Mrs X’s wound healing may be affected by her being “prone to refuse fluids when prompted”.
- An administrator at the care home completed a form to refer Mrs X for NHS Funded Nursing Care (FNC) on 15 May. The form was only partially completed.
- Separate to contact with the care home, Mrs X’s daughter spoke to the Council to arrange a care assessment and to determine if her mother would qualify for NHS Continuing Healthcare (CHC). This led to a review of Mrs X’s needs. The assessment of her needs took place at the care home on 24 May. A social worker and the manager of the care home took part, along with Mrs X’s daughter.
- As at 24 May, the review documentation noted:
- Mrs X had a diagnosis of severe dementia which was likely Alzhiemer’s and various other medical conditions. Mrs X could become confused and anxious, so her daughter advocated for her. Mrs X’s daughter noted the level of deterioration over the past year had been significant. She said, at home Mrs X had not been eating and she was not being encouraged to do so by her partner, who was not able to care for her.
- The care home manager stated Mrs X required the support and assistance of a carer for personal care and dressing. She also required support and encouragement with eating but she would often refuse this assistance. She would also often spit food onto the plate for no apparent reason. He stated Mrs X had a soft diet and normal fluid intake, her weight was currently 60.4kg and her BMI was 23.
- The manager stated Mrs X was restless at night and tended to spend the night in the lounge with staff. Mrs X became anxious if she was alone and was not able to use the call bell. She also had no awareness of danger.
- The assessment was clear that Mrs X’s needs could not be met at home as she needed 24-hour care in a residential dementia placement. A CHC checklist was also done as part of the review. It determined that Mrs X did not meet the criteria for a full CHC assessment.
Summary of Mr X’s concerns
- Mr X considered the FNC referral sent to the NHS by Allington Court on 15 May lacked sufficient detail. He stated the referral form was only sent a few days after Mrs X was admitted to the care home, too soon to have assessed Mrs X properly. He also believed a tick box for “condition deteriorated” should have been ticked on the FNC application. He stated Mrs X’s health was deteriorating and her respite stay had been extended from one to two weeks because of this. The family explained that Mrs X had been deteriorating at home before her admission. He complained the referral did not give the NHS sufficient information to enable it to make a proper decision about CHC. He also stated the family did not receive a factsheet that the care home should have sent. Mr X also complained Allington Court missed the opportunity for fast tracking an assessment for CHC.
- Mr X was also concerned that the care home did not take sufficient action to address Mrs X’s severe weight loss. He noted her weight reduced significantly between admission at Allington Court and her move to residential care. Mrs X was only placed on a food chart on 28 May, around two weeks after admission, even though the care home recorded that she was reluctant to eat and she spat out food.
- Mr X considered the care home manager had a duty to support the social worker with the completion of the CHC checklist. He believed there was sufficient evidence that Mrs X was at the end of her life and warranted a specialist dementia care home with palliative care. He disagreed with the decision taken that Mrs X did not meet the criteria for CHC and that her needs could be met in a residential care home rather than a nursing home. He felt the manager gave inaccurate information to the decision maker. He stated the manager should have been aware that Mrs X spitting food out could be indicative of end stage Alzheimer’s. He felt that the care home manager should instead have fast-tracked Mrs X’s referral for CHC.
- Mr X also complained that Allington Court misled the residential care home that Mrs X had no nursing needs, which was wrong. This led to Mrs X being placed in a residential care home when this did not suit her needs.
Was there fault by the Allington Court?
- I found there was fault in relation to the accuracy and completeness of records kept by Allington Court. Some entries to care plans were undated. Some records were incomplete. This makes it difficult to determine clearly what observations were made about Mrs X and when. There was also some contradictory information about whether Mrs X fell within Bupa’s Band three or Band four.
- On the basis of the evidence, I found that the care home took too little action to properly monitor Mrs X’s eating and drinking and the impact this had on her weight. The initial assessment on 11 May noted Mrs X had a poor appetite. On 24 May the care home manager stated Mrs X had often spat out food and refused help that she needed to eat and drink. However, these are not observations that are recorded in the care notes.
- There is a record on Mrs X’s care assessment that she spat out food, but the entry is undated, so it is not clear when this first became apparent. As the care manager remarked on 24 May that this happened ‘often’, it suggests it had started to occur some time before then. I would have expected a food and fluid intake diary to have been started when these issues began to be observed.
- In addition, at the review meeting on 24 May Mrs X’s weight was stated to be 60.4kg. But this was her weight on admission, not on 24 May. There is no record that Allington Court weighed Mrs X at any time after her admission. Given the apparent concerns about her nutritional intake I would have expected the home to weigh Mrs X to inform the discussion on 24 May or, as a minimum, when it later began a food intake diary on 28 May. Allington Court stated Mrs X’s weight was 64kg on her transfer notes on 11 June. The residential home she moved to found Mrs X weighed 51kg on admission.
- It is clear that Mrs X’s appetite was poor, and had been poor for some time before she went into Allington Court. But, her food and fluid intake should have been better monitored and it is possible that her nutritional intake and weight loss could have been improved had Allington Court taken action sooner. This leaves the family with some uncertainty about whether Mrs X could have been more comfortable had it done so. This causes the family injustice.
Mrs X’s needs assessment / CHC
- I found in the section above that Allington Court should have better monitored Mrs X’s food and fluid intake and documented this more clearly. Because this was not done, the care manager did not provide up to date information about Mrs X’s weight at the review of Mrs X’s needs that took place on 24 May. However, I found the other information provided by the care home was consistent with care records which described how Mrs X presented. The care manager described she was anxious, unsettled and spent a lot of time in the lounge as she did not care to be alone. He also explained the support needed with activities of daily living and with mobility. Mrs X’s daughter had explained Mrs X’s condition had deteriorated over the past year. The care manager also made it known that Mrs X did often reject assistance with eating and she spat out food.
- The points above were considered by the attendees of the meeting. So, aside from the issue of Mrs X’s weight, I did not find the information provided by the care home at this meeting was misleading. I recognise that Mr X disagreed that Mrs X could be cared for in a residential dementia care home setting. He considered the deterioration in Mrs X’s health warranted nursing care, and also should have been treated as a fast-track CHC application. Monitoring someone’s weight and managing their food intake can be done in a residential dementia care or a nursing home setting, so I do not consider the issue of Mrs X’s weight was, in itself, likely to have led to a different outcome. The care home manager was not the primary decision maker. We have separately considered a complaint from Mr X about the Council’s assessment of Mrs X’s needs and the CHC assessment that was carried out alongside this. So, I do not consider any fault by Allington Court affected the decision about CHC carried out on 24 May.
- We considered a separate complaint about the way the Council dealt with the assessment of Mrs X’s needs and the way it went about making its decision about eligibility for CHC funding.
Allington Court’s FNC Application
- Although I have not found the care home’s actions are likely to have affected the review outcome or CHC decision, I note that Allington Court applied for FNC soon after Mrs X was admitted, and before any consideration of CHC.
- Mr X argued that an application for FNC suggests the care home recognised Mrs X had nursing needs, which was inconsistent with the view taken at the review meeting that Mrs X’s needs could be met in a residential setting.
- I am not persuaded the FNC form shows what Mrs X’s needs were. However, Paragraphs 246 to 251 of the National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care explain the process for applying for NHS Funded Nursing Care (FNC). The guidance states that eligibility for NHS Continuing Healthcare must first be considered, and a decision made and recorded, prior to any decision on eligibility for NHS-funded Nursing care. It confirms that people who are not found to be eligible for CHC may still require nursing in a care home setting.
- The Care Home told Mr X that its standard process was to request an FNC assessment from the NHS. In response to Mr X’s complaint the Care Provider stated a registered nurse would then come to the care home to complete an FNC assessment and a mini‑Decision Support Tool (DST). If the nurse assessor considered the mini-DST triggered eligibility for a full CHC assessment, they would return with a social worker to do this. The process being followed does not seem to align with the guidance in The National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care. This specifies that CHC should first be considered.
- Although the process does not align with the government guidance, I do not consider the application for FNC led to any significant injustice to Mr X or his family. I say this because, they separately approached the council to request a CHC assessment. This took place on 24 May.
Information Shared with the Residential Home
- I found Allington Court were at fault in regard to the transfer information provided to the residential care home. This is related to the finding of fault concerning their records and actions concerning Mrs X’s weight loss. The transfer information did not provide a clear picture of the concerns Allington Court had about Mrs X’s eating and drinking or the change in her weight during her stay. This was also fault.
- Had Allington Court better explained the situation, it is possible the residential home would have begun monitoring food and fluids closely from admission. So, this too leaves some uncertainty for Mrs X’s family.
- Within four weeks of my final decision:
- The care provider will review how records are maintained for residents to ensure information is properly captured and updates to care plans are clearly dated.
- The care provider will review its practice in respect of FNC applications taking into account of the National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care.
- The care provider will review how food and drink intake is monitored and acted upon in the light of this complaint and confirm what actions the home will take to change or reinforce correct practices.
- To recognise the uncertainty caused to the family as a result of the failure to maintain proper records and monitor and manage Mrs X’s food and fluid intake, the care provider has agreed to apologise to the family and pay them £300.
- There was fault by the care provider and it has agreed a satisfactory remedy.
Investigator's decision on behalf of the Ombudsman