Summary: Ms X complained about the level of care provided to her mother, Mrs Y, on behalf of the Council, in the weeks leading to her mother’s death. The care home sought medical advice appropriately. However, it was at fault for the loss of some of Mrs Y’s records.

The complaint

1. Ms X complained about the level of care provided to her mother, Mrs Y, by Meadbank Nursing Home, on behalf of the Council. She said the care home did not act on her concerns and was not proactive in seeking medical advice. Mrs Y was later admitted hospital where she was diagnosed with sepsis and died.
2. Ms X considers if the care home had been more attentive, Mrs Y would not have been so sick when she was admitted to hospital and would not have died. She said this caused her significant distress.

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The Ombudsman’s role and powers

3. 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)
4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
5. 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)
6. 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

7. I considered:
• the information Ms X provided and discussed the complaint with her;
• the information provided by the care home and the Council;
• Relevant law and guidance, as set out below; and
• Our Guidance on Remedies.
8. Ms X and the Council had an opportunity to comment on my draft decision and I considered their comments before making a final decision.

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What I found

Relevant law and guidance

Fundamental standards of care

9. 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.
10. These include:
• Care and treatment must be appropriate and reflect service users’ needs and preferences;
• Systems and processes must be established to ensure compliance with the fundamental standards;
• Maintaining a secure, accurate, complete and contemporaneous record in respect of each service user.

What happened

11. The Council arranged Mrs Y’s care at Meadbank Nursing Home when she was no longer able to manage at home. Mrs Y moved to the care home in November 2019. Ms X was happy with the way the Council supported her and her mother. However, we hold the Council responsible for any failings by the care home since it arranged the care.
12. Ms X said she had concerns about the level of care and had decided to move her to another home but she did not formally complain about events prior to February 2020.
13. Ms X said she spoke to the care home in late February 2020 because her mother was not responsive when she tried to phone her and a neighbour who had seen Mrs Y in the care home had told her she was unresponsive during their visit. She said the care home told her the deterioration could be because she was still settling in or due to her dementia getting worse.
14. The care home was not able to provide care records for February 2020 as it said these were missing. However, I have seen records for the period November 2019 to January 2020, and from 3 March onwards. I have also seen care plans and other records, including records of medical visits, contact with relatives and weight monitoring.
15. There were no significant concerns about Mrs Y prior to February 2020. I asked the care home whether it had noticed any deterioration in Mrs Y’s condition during February and if so what action it took to address any concerns. It said it noted Mrs Y had lost weight in late February and had referred her to a dietician. I have seen weight recording records that show this and records to confirm the referral was made.
16. The records show Mrs Y complained of chest pain on 28 February and was seen by a GP. The record states the GP had seen her twice before and found her chest was clear. The GP advice was to give Mrs Y paracetamol and use an ibuprofen gel, as needed.
17. The records show Mrs Y declined most of her meals on 4 March and complained of leg pain. She was given paracetamol. She complained again of leg pain on 7 March and was again given paracetamol. She declined lunch and supper on 8 March and declined lunch on 9 March. On 10 March the record stated she was sleepy and eating less. The care home called the GP, who saw on Mrs Y on 10 and again on 11 March. Also, on 11 March, the care home carried out a urine test, which indicated Mrs Y may have a urinary tract infection (UTI). The GP prescribed antibiotics and the first dose was given to Mrs Y later that day. In the evening, when staff assisted Mrs Y to bed, they found she was unresponsive and called an ambulance. Paramedics decided Mrs Y should go to hospital for observation. On 12 March the hospital told Ms X it was treating Mrs Y for sepsis and on 13 March Mrs Y died.
18. Ms X complained to the care home on 24 March and it responded on 20 April 2020. It explained it had sought medical advice on several occasions, listing the dates it had done so. It suggested she may want to contact the GP for further information and provided their contact details. Ms X was not satisfied with the response because she said urinary sepsis does not develop overnight and it was not appropriate for the care home to refer her to the GP as the care home had ultimate responsibility for Mrs Y’s care.

My findings

19. Care homes are expected to keep daily records of the care provided to residents. The care home was not able to provide full records for February 2020 and, whilst I have no reason to think records were not kept, records should be kept securely and the loss of those records was fault. This fault has caused an injustice to Ms X because it means I cannot now establish whether there were concerns in that period that the care home failed to act on. Therefore, Mrs X cannot be certain about whether the care home did all it could during February 2020.
20. The records I have seen show the care home monitored Mrs Y’s weight on a monthly basis and when it identified a weight loss in late February, it referred her to a dietician. This was appropriate action for it to take. The GP saw Mrs Y on 28 February, at which point the GP did not have concerns about her health.
21. The records show Mrs Y was eating less from 8 March and on 10 March she was reported to be sleepy. At this point the care home called the GP and carried out a urine test, both of which were appropriate actions to take. The GP prescribed antibiotics for a suspected UTI on 11 March and the first dose was given the same day. Mrs Y deteriorated before the antibiotics could take effect and was admitted to hospital later on 11 March.
22. Although Ms X considers the care home should have sought medical advice sooner, the records do not show any concerns that would warrant this before 10 March. Therefore, I cannot conclude there was fault leading to injustice.
23. I note Ms X’s concern that the care home’s complaint response consisted of a list of dates it had sought medical advice. It would have been better if the response had provided more of a narrative to show the action it had taken and the context in which was taken. However, I do not consider this is sufficient to warrant a finding of fault. It was not fault to suggest Ms X contact the GP since the GP had seen Mrs Y a number of times and may have been able to provide more detailed information about her health.

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Agreed action

24. The Council will, within one month of the date of the final decision, remind the care home of the importance of keeping care records securely.
25. In my draft decision I recommended the Council apologise to Ms X for the uncertainty caused by the loss of care records for February 2020 but Ms X told me she did not want to receive an apology.

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Final decision

26. I have completed my investigation. I have found fault causing injustice. I have recommended action to remedy the injustice.

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Investigator's decision on behalf of the Ombudsman