Summary: Miss X complained about the care provided to her late mother by the Council commissioned care home. The care provider was at fault as it failed to seek prompt medical attention, delayed completing food and fluid charts and failed to properly complete elimination charts. The Council has agreed to apologise to Miss X and make a payment to acknowledge the distress and uncertainty caused to her by the care provider’s faults. It has agreed to ensure the care provider takes action to prevent a recurrence of the faults.

The complaint

1. Miss X complained the Council commissioned care home, Kirkwood Court, failed to provide her late mother, Mrs Y, with adequate care and delayed contacting the GP when Mrs Y’s condition deteriorated. Miss X says when her mother entered hospital, she was dehydrated with damaged skin round her bottom which caused her and her late mother significant distress.

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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 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). In this case the care provider was commissioned by the Council so was providing services on its behalf.
4. We normally name care homes in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home. (Local Government Act 1974, section 34H(8), as amended)
5. 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.
6. 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)

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How I considered this complaint

7. I have considered the information provided by Miss X and have spoken with her on the telephone. I have considered the information provided by the Council.
8. I gave Miss X and the Council the opportunity to comment on a draft of this decision and considered the comments I received in reaching a final decision.
9. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share the final decision with CQC.

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What I found

10. 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
• Regulation 9 requires care and treatment to be appropriate and person-centred based on an assessment of their needs and preferences.
• Regulation 10 sets out that service users must be treated with dignity and respect. Staff must respect people’s personal preferences, lifestyle and care choices.
• Regulation 17 is about good governance. This includes keeping accurate, complete and detailed records about people receiving care, including records of care provided and decisions made relating to care.
11. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (section 42, Care Act 2014)
12. The Council’s safeguarding procedures say if the Council receives concerns about the welfare of a vulnerable adult, it should decide within two working days whether an investigation under section 42 of the Act is required.
13. At the end of the investigation, a written report should be sent to the Safeguarding Adults Manager. The Council must then determine with the adult what, if any, further action is necessary to protect the person from abuse or risk. These actions should be set out in a protection plan.
14. A safeguarding case can be closed at any stage, provided there is an agreement of how issues will be followed up with the adult.

What happened

15. Mrs Y had Alzheimer’s disease and other physical conditions. She moved into the care home in 2016. Mrs Y used continence pads as she was incontinent of urine but would also use the toilet and was regularly assisted to the toilet by staff. Mrs Y ate a normal diet.
16. In July 2020 the Council reviewed Mrs Y’s care package. It noted the care home was meeting Mrs Y’s needs and she appeared settled and content.
17. The care home’s daily records show Mrs Y was mainly settled throughout September 2020 and was eating and drinking. On 26 September Mrs Y complained of feeling unwell and the care home called an ambulance. Mrs Y was taken into hospital for further tests.
18. Mrs Y was discharged the next day and returned to the care home with a five day course of antibiotics.
19. On 27, 28 and 29 September care staff noted Mrs Y had a poor food and fluid intake. Miss X was due to speak to her mother on skype on 28 and 29 September but the care provider cancelled the calls. On 29 September a staff member noted ‘if no improvement tomorrow contact GP’. The following day the care home noted Mrs Y got dressed and was assisted to the lounge. She had a good food and fluid intake.
20. On 1 October the daily records noted Mrs Y was ‘incontinent a few times today, loose, personal care given’. On 2 October they noted Mrs Y requested to remain in bed in the morning, complaining of feeling unwell. They noted she had loose stools before tea. On 3 October the records noted Mrs Y spent the day in her room, maintained a fair diet/fluid intake and was relaxing in her chair watching tv.
21. On 4 October Mrs Y was assisted with a shower and was settled in the foyer. She had a poor diet and fluids. She stayed in bed until late the following day.
22. On 6 October Mrs Y had a skype call with her daughter Miss X. Miss X says she asked staff whether they thought the antibiotics were working as she was concerned Mrs Y was not herself. Staff noted Mrs Y had a poor food and fluid intake even with encouragement.
23. Mrs Y was sleepy the following day and refused her evening meal. She was assisted to the dining room on 8 October to improve her eating. The records noted she had loose stools in the afternoon. On 9 October the records again noted Mrs Y was sleepy with poor food and only a fair fluid intake.
24. On 10 October the care provider started to complete food and fluid charts for Mrs Y. Mrs Y did not eat her breakfast or lunch and did not meet her fluid target. In the daily records staff noted Mrs Y had loose stools on three occasions. The care home also completed an elimination chart. The chart used codes to record continence. If bowels were opened it stated B.O. The form stated ’enter code – refer to Bristol Stool Chart overleaf’ for monitoring stools. Staff noted on the chart on 10 October Mrs Y opened her bowels on three occasions. The care home did not record any code to reflect the nature of those bowel movements.
25. On 11 October staff noted Mrs Y seemed more alert. She continued to have loose stools but her fluid intake had improved. Staff changed Mrs Y’s pad seven times and on five of these Mrs Y’s pad was soiled/bowels opened.
26. On 12 October staff noted Mrs Y had very loose stools again and very poor mobility during the night. The elimination chart recorded staff assisted Mrs Y seven times between 02:20 in the morning and 23:35 in the evening, changing her pad on each occasion, assisting Mrs Y to the toilet four times and on three occasions the pad was soiled. The food and fluid chart showed Mrs Y ate around half of all her meals and had an improved fluid intake. Miss X was due to have a skype call with Mrs Y but this was cancelled by the care home. Miss X requested the care provider call the GP. It did not do so.
27. On 13 October Mrs Y had very loose stools in the morning and very poor mobility during the night. She was very sleepy. She refused personal care and ate and drank very little. On the elimination chart staff recorded they changed Mrs Y’s pad three times in the morning. She refused assistance through the afternoon and staff changed her pad again at 21:00. Miss X spoke to the care home. A staff member asked if she wanted the GP called. Miss X was concerned the care home had not done so already. The GP arranged for the care home nursing team to visit Mrs Y the next day.
28. On 14 October the care staff noted Mrs Y had loose stools during the night and her mobility was poor. Staff recorded on the elimination chart they changed Mrs Y’s pad five times between 02:00 and 14:00 and on each occasion it was soiled. Miss X says she insisted the care home seek medical help. The GP was contacted and arranged Mrs Y’s admission to hospital. Miss X visited Mrs Y in hospital on 16 October. She says the nurse told her Mrs Y’s skin on her bottom had broken down due to it being in contact over time with diarrhoea.
29. Miss X emailed the care provider on 19 October to complain about the care provided to her mother. She said Mrs Y was dehydrated with severe diarrhoea and at no time had the care home told Miss X how ill her mother was.
30. The care home telephoned the hospital on 20 October. Mrs Y was having intravenous fluids. The hospital had diagnosed a terminal illness. The care home rang Miss X to ask if she wanted Mrs Y to return there for end of life care. Miss X was extremely upset and refused this. She was concerned Mrs Y had severe dehydration and diarrhoea when she was admitted to the hospital.
31. On 21 October the care provider raised Miss X’s concerns as a safeguarding concern with the Council. The Council decided it should progress through the safeguarding procedures.
32. The care provider completed a safeguarding adults investigation report. It noted medical intervention was not sought in a timely manner and possibly delayed Mrs Y’s diagnosis. It highlighted lessons to be learnt that:
• The GP should be informed if a resident had diarrhoea for more than two days;
• It should use the RESTORE2 (a physical deterioration and escalation tool for care homes) as a protocol when seeking medical intervention
• Food and fluid charts should be implemented for any resident who presents unwell or has a change in presentation.
33. The safeguarding did not progress to a strategy meeting and Miss X was not informed of the outcome.
34. Mrs Y died in early November 2020.
35. The care provider responded to Miss X’s complaint in late November 2020. It noted staff had cancelled skype calls with Miss X and apologised she was not given an explanation for the reasons for this at the time. It said staff were monitoring Mrs Y and there were days when Mrs Y was presenting as her usual self and eating and drinking well. There were also days when she was tired and had loose stools. It said staff were monitoring her closely. It said on 12 October the senior on duty assessed a GP call was not necessary as Mrs Y was eating and drinking and was well in herself on that day.
36. It considered staff had missed opportunities to have Mrs Y’s well-being reviewed by a GP and although this would not have been a factor in her deterioration it would have provided Miss X with some reassurance. It noted staff called the GP on 13 October and the GP was called again on 14 October when Mrs Y deteriorated. It apologised that staff did not contact her earlier to advise her of Mrs Y’s rapid deterioration. It said there was no evidence of any tissue breakdown prior to Mrs Y’s hospital admission. It said it contacted the hospital which said Mrs Y was not dehydrated but had low potassium levels. It said on reviewing the records relating to communication with Miss X it considered they were very poor and apologised for this. It said it would look at the concerns she raised to see where it could and should improve.
37. Miss X remained unhappy and complained to the Ombudsman.

Findings

38. Mrs Y was discharged from hospital with antibiotics for a suspected infection. On that basis the care home may have expected her to have been under the weather for two to three days. However, the care records show Mrs Y was sleepy with a poor food and fluid intake. She had loose stools noted in the daily records from 1 October onwards. Miss X had also raised concerns about Mrs Y’s condition following skype calls being cancelled and due to Mrs Y’s presentation when they had skype calls. The care provider did not contact the doctor until 13 October. This delay in contacting the doctor was fault.
39. The care home did not properly complete the elimination records. This was fault. The form says staff should use the Bristol Stool Chart to categorise stools following a bowel movement. This was not done on any occasion on the elimination chart. It was therefore not obvious from the stool chart the frequency that Mrs Y had loose stools.
40. The care home did not start food and fluid charts until 10 October despite Mrs Y not eating and drinking consistently since she came out of hospital. This delay was fault. Had it done so it may have taken action sooner to address this.
41. The care home was at fault as it failed to keep Miss X properly updated about Mrs Y’s condition.
42. The care provider acted appropriately by referring Miss X’s concerns to the Council as a safeguarding concern. The safeguarding investigation did not proceed to a strategy meeting. If the Council was satisfied that the risks were managed it was open to it to decide to end the investigation. However, there is no evidence it discussed the safeguarding or its outcome with Miss X or advised her of its closure. It did not advise her of the steps taken or any lessons learned following the safeguarding. This was fault.
43. The care provider identified lessons to be learned from the safeguarding investigation. There is no evidence the Council followed this up to ensure the actions were carried out. This was fault.
44. When Mrs Y entered hospital she was diagnosed with a terminal illness and it is highly likely this was the cause of her rapid deterioration. Had the care provider sought medical attention more promptly, this would have been diagnosed sooner.
45. Miss X considers that the skin on her mother’s bottom broke down as a result of neglect by the care home. Miss X says a nurse at the hospital told her this was due to exposure to diarrhoea for a long period and that a hospital doctor told her of his concerns about the skin on Mrs Y’s bottom soon after she went into hospital. The care home had no records of skin damage, but its records show Mrs Y regularly had loose stools in the care home. We have not had sight of the hospital’s records as part of this investigation and I do not consider it proportionate to request them. Even if the hospital’s records showed that Mrs Y’s skin was already damaged when she entered hospital, we would not be able to establish whether this would have been avoided if the care provider had acted without fault. In reaching this conclusion, I have also taken into account that the hospital did not make a safeguarding referral regarding the skin damage. However, Miss X is left with a sense of uncertainty over whether the damage to Mrs Y’s skin could have been prevented and this caused her significant distress.
46. The records show Mrs Y was receiving an intravenous drip in hospital, she had loose stools over a significant period and had a poor food and fluid intake. The delays in the care home seeking medical attention caused Miss X avoidable uncertainty, as to whether her mother’s skin, and general health would have deteriorated to the extent it had if it had sought medical intervention sooner.
47. Mrs Y has died and therefore any injustice caused to her by the faults identified cannot be remedied.
48. Miss X was caused distress by the faults identified and has been left with a sense of uncertainty over what would have happened had medical attention been sought sooner. The injustice of distress cannot generally be remedied by a payment, so we seek a symbolic amount to acknowledge the impact of the fault. The Ombudsman usually pays between £100 and £300 for distress. I consider a payment of £300 would be appropriate in this case.

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Agreed action

49. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the care provider, I made recommendations to the Council.
50. Within one month of the final decision the Council has agreed to apologise to Miss X for the care provider’s failings and for failing to provide her with the outcome of the safeguarding investigation. It has agreed to pay Miss X £300 to acknowledge the uncertainty and distress caused to her by the care provider’s failure to seek prompt medical attention and for failing to keep her updated about her mother’s condition.
51. Within three months the Council has agreed to remind relevant staff of the need to feed back the outcome of a safeguarding investigation to the person affected or their relatives. It should also ensure it follows up the outcome of a safeguarding investigation to ensure any recommended actions are carried out.
52. Within three months the Council has agreed to ensure the care provider:
• Retrains staff to ensure elimination charts are properly completed.
• Reminds staff to ensure food and fluid charts are implemented promptly whenever a resident appears unwell.
• Retrains staff to ensure medical attention is sought promptly when a resident appears unwell or has a change in presentation. This may be through the use of the Restore 2 tool, as referred to the in the safeguarding investigation report.

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Final decision

53. I have completed my investigation. There was evidence of fault causing injustice which the Council has agreed to remedy.

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Investigator's decision on behalf of the Ombudsman