Summary: Mr and Mrs B complained that Mr B received inadequate care during a respite placement. We found the care provider failed to provide an adequate service to Mr B causing him avoidable harm and the distress and inconvenience of an overnight hospital stay. This also caused Mrs B avoidable distress. We also find the care provider failed to keep full and accurate records about Mr B. To remedy the injustice caused, the care provider has agreed to make a payment to Mr and Mrs B.

The complaint

1. Mr and Mrs B complain that Mr B received inadequate care during a respite placement at Hamilton House. This caused him avoidable discomfort and the distress and inconvenience of an overnight hospital stay. It also caused Mrs B avoidable distress.

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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. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. 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)
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 have considered all the information provided by Mr and Mrs B, made enquiries of the care provider and considered its comments and the documents provided. I have also considered the safeguarding investigation completed by the local council.
7. Mr and Mrs B and the care provider 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

Legal and administrative background

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 9 states that the care and treatment of service users must: be appropriate; meet their needs; and reflect their preferences.
10. Regulation 12 states providers must assess the risks to people’s health and safety during any care or treatment and make sure staff have the qualifications, confidence, skills and experience to keep people safe. The intention of this regulation is to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm.
11. Regulation 14 states care providers must make sure people have enough to eat and drink to meet their nutrition and hydration needs and receive the support they need to do so. The intention of this regulation is to make sure service users have adequate nutrition and hydration to sustain life and good health and reduce the risks of malnutrition and dehydration while they receive care and treatment.
12. Regulation 17 states that care providers must keep accurate, complete and detailed records for each person using the service.

Key facts

13. Mr B has Parkinson’s disease and dementia. He lives at home with his wife, Mrs B, who cares for him with the assistance of carers. In August 2020 Mrs B suffered an injury. Mr B went to stay in Hamilton House care home (‘the Home’) for two weeks’ respite to allow Mrs B to recover.
14. The care provider completed a pre-admission assessment which noted that Mr B could not do anything without assistance and needed help with all aspects of personal care.
15. Mr B was admitted to the Home on Friday, 21 August 2020.
16. Mrs B says that when she visited on 25 August 2020 Mr B was very sleepy. The following day when Mrs B arrived Mr B was not wearing his hearing aids, was only wearing his top dentures, was unshaven and the front of his shirt was very wet because he was not wearing his bib despite Mrs B having provided seven of these as he needs to wear them constantly. Mr B was also not wearing a cardigan and was cold. Mrs B spoke to the care home manager and asked her to investigate these issues.
17. Mrs B visited again the following day. She noticed Mr B had not drunk the drink in his beaker. When she opened it, it was full of liquid which had separated with thick scum floating on the top. She called the office and asked to speak to the home manager who apologised. Mrs B was concerned about the care Mr B was receiving and decided to bring him home as soon as she could arrange carers.
18. Mrs B says that when she visited on 28 August 2020 Mr B was again very sleepy and mumbling and appeared not to understand what she was saying. She was concerned but relieved that she had now arranged carers for the following week so Mr B would be returning home in a few days.
19. On 31 August 2020 Mrs B again found Mr B to be very sleepy. He did not seem to know who she was and was talking nonsense. She says she had never seen him like this before.
20. Mrs B collected Mr B from the Home the following day. She says that when she arrived he looked uncharacteristically confused and very sleepy. They arrived home at about 1.30 pm. Carers arrived at 3 pm and were unable to wake Mr B or get any response. Mrs B telephoned the doctor who advised her to call an ambulance. The paramedics arrived and found Mr B unresponsive. They took him to hospital. On arrival Mr B was found to be severely dehydrated. The hospital also found: pressure sores on his right ankle; sores on his left foot; severe redness and soreness on his bottom and halfway up his back; and a large cut to his knee. Mr B was put on a drip and kept in hospital overnight under observation.
21. Mrs B complained to the care provider and the Home manager responded. As regards Mr B not wearing his hearing aid, dentures, cardigan and bib, the manager said she had spoken to all members of staff that had cared for Mr B. They explained they were allowing him to remain as independent as possible. He would often refuse interventions and they would respect his wishes. She explained that, in future, during respite stay, the named nurse will speak to the next of kin daily and discuss the care planning of their loved ones and any issues they might have. This would improve communication with family members.
22. The manager apologised for the failure to renew the drink in Mr B’s beaker and said she had reinforced with staff the need to check bedrooms and drinking receptacles.
23. As regards Mr B’s wounds, the manager said that, when residents are admitted to the Home, staff conduct a skin inspection document as part of the admission process and consider the information provided in the pre-admission assessment. She said the nurse on duty had failed to complete this document. She said that, on 30 August 2020, the nurse on duty documented a graze on Mr B’s knee and a red area on his toe but did not document any areas of pressure damage or broken skin. She confirmed that completion of the required body mapping process would be discussed with the staff member.
24. The manager apologised to Mr and Mrs B and agreed to waive the fees for the care Mr B did not receive after he left the Home.
25. The care provider raised a safeguarding concern with the local council. A safeguarding concern was also raised by the community nurse who had visited Mr B.
26. The council completed a safeguarding investigation which focused on: the injuries Mr B had on discharge; being dehydrated on discharge resulting in him requiring fluids at the emergency department; and insufficient documentation. The investigation substantiated the allegations of neglect and acts of omission by Hamilton House and recommended specific actions including:
• improving record keeping, including daily notes;
• ensuring drinks in bedrooms are checked and changed;
• contacting family members for support if there are any concerns;
• updating their medication policy around when to contact the GP if medication is missed or refused;
• completing and updating policies on admitting residents, for example completing body charts.

Analysis

Dehydration

27. Mr B’s care plan stated that he was “fully dependent on staff to deliver personal care, washing and dressing, feeding, cleaning, toileting, mobilising”. It said “he needs full help to eat and drink”.
28. Under Regulation 14, the care provider was under a duty to ensure Mr B had enough to eat and drink to meet his nutrition and hydration needs and provide him with the necessary support he needed to do so. It clearly failed to comply with this duty as Mr B was severely dehydrated on discharge and was admitted to hospital and placed on a drip as a result.
29. Mrs B also found evidence that Mr B was not being given fresh fluid regularly when the beaker in his bedroom had thick scum floating in it. The manager acknowledged that she witnessed this. Several times when Mrs B visited, Mr B was uncharacteristically sleepy and confused. This also indicates he was not receiving regular fluids. Despite this, there is no evidence that the Home reported any concerns about Mr B not drinking enough to Mrs B or to Mr B’s GP.

Skin injuries

30. The pre-admission assessment contains a body map showing no issues and stating that Mr B’s skin was “intact at present”. However, it stated that he was at high risk of pressure sores.
31. Mr B’s care plan stated his skin was “at risk”. It said staff should protect his skin with barrier creams if needed and reposition him during the day and use appropriate cushions.
32. The care provider says that, as Mr B was assessed as at risk of tissue damage, he was supported to change his position and this was recorded using a repositioning chart.
33. The care provider accepts a body map was not completed on admission as it should have been. No injuries were documented until 30 August 2020. This suggests this was the first time the injuries developed or were noticed by staff. Notes on the daily record state it was believed the graze on Mr B’s knee was from the bed rail padding and the red area on his left foot was believed to be from his slipper.
34. There is no evidence to suggest the Home contacted Mr B’s GP about the injuries. The GP confirmed the home had not been in contact.

Missed medication

35. The daily care records indicate that Mr B declined his medication. The care provider should have informed Mrs B or Mr B’s GP that he was not taking his medication as some of this was for his Parkinson’s disease.

Record-keeping

36. Mr B was at the home from 21 August 2020 until 1 September 2020. No daily records were kept for 21-26 August or 31 August 2020 (seven days out of the 12 Mr B was at the care home). The records that were completed are very brief. There is no reference to Mr B’s food and liquid intake apart from an entry on 30 August 2020 which states “he had about ¼ of his lunch, ½ his pudding + a beaker of juice”. There is also no reference to Mr B refusing interventions.
37. As referred to above, the care provider failed to complete a body map when Mr B was admitted to the Home.
38. Under Regulation 17, the care provider is required to maintain accurate, complete and detailed records. It failed to do so and this causes uncertainty about the care Mr B received.

Conclusions

39. I find the care provider failed to provide the level of care Mr and Mrs B had the right to expect. The failure to ensure Mr B was adequately hydrated was a significant matter and caused him harm. He suffered the distress and inconvenience of an overnight hospital stay as a result. He also suffered skin injuries causing pain and distress.
40. Mrs B also experienced avoidable distress and anxiety because of the poor care Mr B received. The whole purpose of the period of respite care was for her to recover from an injury sustained whilst caring for Mr B and to rest. Instead, she says the experience had a profound effect on both of their physical and mental health.
41. The failure to keep adequate records relating to Mr B’s care causes Mr and Mrs B uncertainty about the care he received.

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Agreed action

42. The care provider has agreed that, within one month, it will:
• send us details of how it has complied with the recommendations in the safeguarding report;
• pay Mr B £1500 in recognition of the pain, distress and inconvenience he suffered as a result of the poor care he received; and
• pay Mrs B £500 in acknowledgement of the distress and anxiety she suffered because of her husband’s poor care.

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Final decision

43. I find the care provider’s actions have caused Mr and Mrs B an injustice.
44. I have completed my investigation on the basis that the care provider has agreed to implement the recommended remedy.

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Investigator's decision on behalf of the Ombudsman