Summary: The care provider did not provide good enough care and treatment to the late Mr X while he was resident at the care home. It failed to provide food in a way he could easily consume it and failed to administer medications properly in accordance with its own assessment. The care provider will review the way it monitors food intake and the action it takes on the results. It will apologise to Mr X’s family and offer a payment in part waiver of its fees and in recognition of the distress its failings caused.

The complaint

1. Mrs A (as I shall call the complainant) complains about the care and treatment of her late father in Lynwood Court care home. In particular she complains that he suffered weight loss in the home such that he was malnourished when admitted to hospital, and care staff did not take action when he could not chew or swallow food even though the family alerted them. She complains that staff told her they were ‘too busy’ to make sure he took his medication despite that assurance on his care plan.

Back to top

The Ombudsman’s role and powers

2. 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. If they have caused an injustice we may suggest a remedy (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
3. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.

Back to top

How I considered this complaint

4. I considered all the information provided by the care provider and by Mrs A. Both Mrs A and the care provider had the opportunity to comment on a draft of this statement before I reach a final decision.
5. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Back to top

What I found

Relevant law and guidance

6. 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.
7. Regulation 14 says the nutritional and hydration needs of service users must be met. It says “Providers should have a food and drink strategy that addresses the nutritional needs of people using the service.” It says “People’s food must be placed within their reach and presented in a way that is easy to eat, such as liquidised or finger foods where appropriate” and “People ...should receive appropriate support, which may include encouragement as well as physical support, when they need it.”
8. Regulation 12 says “Staff must follow policies and procedures about managing medicines...including administration.”
9. The NICE guidance “Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition” (updated 2017) states: “People who present with any obvious or less obvious indicators of dysphagia …should be referred to healthcare professionals with relevant skills and training in the diagnosis, assessment and management of swallowing disorders.”

What happened

10. Mr X was discharged from hospital to the care home in July 2019. The pre-admission assessment completed by the care provider noted that he ate well but added that he had been prescribed fortisip (a fortified milkshake) while in hospital and would require ‘full fortified shakes’. The section about his weight and nutrition was not completed. The form stated he should have a nutritional assessment completed on admission to the home. The form also identified that his medication should be administered by staff.
11. The home’s records for 1 July 2019, the day of his admission, record “New resident admitted to us for 4-5 weeks respite with history of reduced mobility, reduced weight due to poor appetite...he is on fortisips daily.” A diet notification form was completed on 12 July which stated that he had a high MUST (malnutritional universal screening tool) score and required 3 smoothies or shakes a day: “weekly weights and food charts introduced”. His weight on 12 July was 48.7 kg. The contract was renewed on a rolling two-week basis.
12. Mr X’s care plan stated “Qualified staff to administer medication in line with prescription”. In respect of nutrition, it said his weight should be monitored and reported if he lost weight: “he needs to be supervised and encouraged to eat food according to his diet”.
13. The records show his appetite was sporadic over the next few weeks. Notes for 17 and 18 July state staff were encouraging him to eat by putting a small portion of food on his plate ‘to encourage him’ then returning with more some time later….”it works well”. His noted reluctance to take the fortisips continued. He was admitted to hospital on 25 July complaining of stomach pains and returned to the home on 31 July.
14. The records for August and September show Mr X’s appetite and food intake fluctuated. On some days he was described as having a good appetite although the food intake charts record what he was offered, not the amount he ate. On other days the records note his poor appetite, that he ate and drank very little and that he “looked quite frail”. On 2 September it was noted he was complaining about a sore mouth and that Mrs X had brought in the medication prescribed for him by his GP for oral thrush.
15. On 13 September the care provider did another nutritional assessment of Mr X. He was recorded as being at “very high risk – consider recording dietary intake daily/weighing weekly/liaising with GP and/or dietician”. His BMI was below 17 (clinically underweight).
16. Mrs A says the family often used to visit at mealtimes and were concerned about the difficulty Mr X had in chewing and swallowing his food. On 26 September Mrs A’s sister emailed the home manager expressing concern that Mr X had lost weight and asked for the care provider to look into it – she said her mother had brought more fortisips for him. She also asked for assurance that staff were ensuring he took his medication. The manager replied she had passed on the query to the house leader to reply. By 1 October Mrs A’s sister emailed again to say she had heard nothing, Mr X was eating “hardly anything” and was getting weaker by the day.
17. On 30 September Mr X’s care needs were reviewed. It was noted that his appetite remained poor, his weight was decreasing and he had been “referred to the GP for further management”. Mrs A points out this was organised by his family not by the care home. A note was added to his care plan: “Make sure that his foods are well presentable and in small portions to stimulate his appetite. Weigh him weekly and encourage him to take his supplements”.
18. The manager replied on 2 October. She said, “Both nurses have assured me that they are staying with dad whilst taking medication. This is part of our policy and our duty as nurses so rest assured this will continue to happen”. She said his weight was now 46.6kg and he had lost 2.2kg since admission. She said he did not like the home’s homemade shakes and kept refusing them so he was being given 2 fortisips a day, as well as being on a fortified diet. She said “dietician referral can be completed where needed.”
19. On 4 October Mrs X took her husband to his GP for an appointment. He was admitted to hospital. The admission note describes his weight loss and poor nutrition. He was discharged to a nursing home on 25 November. The discharge note described his poor nutritional state and mild dysphagia at the time of admission. He was assessed by the Speech and Language Therapy team (SALT) for his poor swallow during his stay in hospital and recommended for a pureed diet.

The complaint

20. Mrs A cleared her father’s room at Lynwood Court on 22 November. She wrote to the manager on 4 December with a complaint. She said the family was “utterly disappointed” with the last few weeks of his care in the care home which had resulted in his hospital admission. She said “my mother took him to his local doctor and she was appalled at his condition and said that he was malnourished/anorexic and asked how he got to this situation.” She said as well as the emails from her sister in late September she herself had asked one of the nurses for an urgent appointment with a nutritionist, but this had not happened. She said she could not believe the care home had not noticed how little her father was actually eating, rather than just recording what he was offered. She asked why the home had not considered pureeing his food.
21. Mrs A also complained that staff had not always administered Mr X’s medication. She said a pill had been noticed on the floor of his room, and on several occasions they had arrived for visits to find his medication still on his table. She said ‘My sister was told by the carers that ‘they don’t have time to check whether the patients take their pills’ – when she asked why the medication was still there.’
22. Mrs A also complained the chair in Mr X’s room was unsuitable for him. She said there had been an ant infestation in the room. His pillows were thin and unsuitable for his injured neck. On occasions his emergency bell had not worked and he had apparently been on the floor for two hours before anyone found him. She said the room was in a shocking state when they cleared it with ‘coffee cups and food left to rot’, and she supplied photographs.
23. The care home manager replied in full in February 2020. She said it would not have been possible for a nutritionist to see Mr X or any resident within 24 hours and a referral to a dietician would have had to be made by a GP. She said Mr X was very frail and had started to decline meals. She said he had full capacity and they had to respect his wishes to decline food although she said they continued to encourage him. She said they never saw any difficulty with his swallowing and he never mentioned it. She apologised if Mrs A thought this had been missed. She added that he had a sore mouth for which he was prescribed medication, which was a contributory factor to his poor appetite.
24. The manager said the chair in Mr X’s room was a standard nursing home chair and the physiotherapist who attended Mr X had not said it was unsuitable. She acknowledged there had been an ant infestation in the home which had been reported to the maintenance team. She said there were no reports of the emergency bell being out of use, and the only time Mr X had been found on the floor after a possible prolonged period was when he had fallen and paramedics had been called. She said alternative pillows could have been provided if asked. She acknowledged the state of the room when the family cleared it was “totally unacceptable”. She did not mention the medication concerns.
25. In August 2020 the care provider sent an invoice to Mr X for the outstanding balance of £12138.12.
26. Mrs A complained to the Ombudsman. She said the care provider should have alerted medical professionals to Mr X’s condition much sooner. She said as it was he spent two months in hospital after being admitted with malnutrition from the home. She says the care provider should have written off the debt for care her father did not receive.
27. The care provider says Mr X had capacity and it was his decision what he chose to eat and drink. It says it cannot force people to eat.
28. Mr X died in May 2021.

Analysis

29. The care provider did not comply with its care plan of ensuring Mr X had three fortisips or supplements a day. Its use of food charts did not reflect the amount Mr X actually consumed. It failed to take action when it was clear that he was having difficulty chewing or swallowing, whether that was a result of dysphagia or because he had a sore mouth from oral thrush (it is noteworthy that Mr X was placed on a pureed diet after the assessment by the SALT team in hospital, yet the care home manager said staff had not noticed any difficulty and he had had a normal textured diet all the time). Had the care provider acted on any of those three relatively simple indicators, it could have avoided the weight loss Mr X suffered.
30. When the care provider undertook a further nutritional assessment in early September and noted Mr X’s very high risk, it failed to act appropriately on the results by referring direct to Mr X’s GP, to a dietician or to the SALT team. By the beginning of October, after the nutritional assessment and in response to the family’s concerns, the manager still indicated she could refer to a dietician but did not do so.
31. Mr X was already underweight when he was admitted to the home but the care provider failed to take the opportunities presented to maintain or improve his weight. It was not good enough for the care provider simply to maintain that as Mr X had capacity it was his choice to refuse food and drink without taking all possible steps to enable his food intake. That caused injustice to Mr X and distress to his family. It was also a failure to comply with the CQC regulation.
32. The manager assured Mrs A’s sister that staff administered Mr X’s medication but the family saw tablets on the floor as well as medication left on Mr X’s table. They say staff told them they “didn’t have time” to supervise residents taking medication. The care provider failed to respond to that point in its complaint response and on the balance of probability it appears there was a failure to comply with the care plan and with the regulations.
33. The other matters which Mrs A raised in her complaint were largely rebutted by the manager on the basis that they had not been reported at the time. The manager did acknowledge and apologise for the very poor state Mr X’s room had been left in.

Back to top

Recommended action

34. Within one month of my final decision, the care provider will review its use of food charts to ensure they accurately reflect consumption;
35. Within one month of my final decision the care provider will review its criteria for referral to the SALT team and the dietician;
36. Within one month of my final decision the care provider will review the way in which it ensures staff administer medication as stipulated by the care plan;
37. Within one month of my final decision the care provider will waive the sum of £1000 from any outstanding debt in recognition that its actions caused injustice to the late Mr X and its standards fell below what was expected; it will also offer £500 to his family in recognition of the distress caused to them by the poor care and treatment of Mr X.

Back to top

Final decision

38. I have completed this investigation and find that the actions of the care provider caused injustice to the late Mr X and his family, which completion of the recommendations set out at paragraphs 34 – 37 will remedy.

Back to top

Investigator's decision on behalf of the Ombudsman