Summary: The complainant raises concerns that the Care Provider failed to update family about a deterioration in her aunt’s health. This resulted in her being unable to see her aunt before she lost consciousness. I find no fault in the actions of the Care Provider, it acted appropriately in difficult circumstances in part created by COVID-19. The Care Provider is however at fault for failing to properly monitor fluid intake, amend care plans and record follow up action after NHS advice. This has caused the complainant uncertainty about whether the Care Provider supported her aunt properly. The Care Provider has agreed to make procedural changes and a payment to the complainant.

The complaint

1. Mrs C complains about the actions of Burrows House, a residential care home operated by Gold Care Homes, the “Care Provider”, when supporting her late aunt, Ms D. For confidentiality I have not used the names of the parties involved.
2. Mrs C complains that Burrows House did not properly care for Ms D. It also failed to tell her about a deterioration in Ms D’s health. This resulted in her not having an opportunity to speak with Ms D before she became unresponsive, or to consider alternative care.
3. Mrs C would like the Care Provider to take action to prevent the same mistakes happening in the future. She also considers the Care Provider should waive the care fees.

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The Ombudsman’s role and powers

4. 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)
5. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
6. 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)
7. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable. (Local Government Act 1974, section 26A(2), as amended)

8. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)

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How I considered this complaint

9. I spoke with Mrs C and made written enquiries of the Care Provider. I considered the response to enquiries and the following information:-
• 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), the regulator of care services has issued guidance on how to meet the fundamental standards below which care must never fall. I considered the fundamental standards and 2014 Regulations when deciding about fault.
• the Care Provider’s care records;
• the Care Provider’s policies;
1. Deteriorating Health of a Resident
2. Contact With-Visits by Family and Friends
10. The Care Provider and Mrs C were provided with an initial draft of this statement. The Care Provider submitted additional information which when taken into consideration changed my view on the complaint. A second draft was issued to both parties.
11. Mrs C and the Council 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

What happened

12. Ms D lived in her own home. To have extra support and company during the lock down period of COVID-19 she entered a residential care home for respite care. The Care Provider completed a “pre-admission” assessment. This included information about Ms D’s needs, likes and preferences. Ms D’s partner was the named contact and provided information about Ms D’s needs. However, the Care Provider says the information provided underestimated the amount of care Ms D needed. The Care Provider did not record a second contact name in the pre-admission assessment. The Care Provider says no other contact details were provided at the time.
13. Ms D entered the care home on 3 July 2020. Ms D was mobile and used a walking frame. She had a history of falls and needed support from another person with transfers and some of her care. Care staff noted a red mark on her sacral area. They recorded this on a body map. The care records note Ms D’s family came to visit on 8 July.
14. The next day the Care Provider was concerned Ms D was not eating or drinking and her mobility had worsened, it therefore contacted the GP via video call. At this point Ms D had started to use a wheelchair. The GP advised staff to take vital signs and report back. On the same day, the Care Provider referred Ms D to the Speech and Language Team, “SaLT” as she was finding it difficult to eat.
15. Care staff amended Ms D’s care plan to account for the need for a wheelchair and a hoist if her mobility was poor. Staff also amended the care plan to include the instructions from SaLT and the use of a teaspoon to help with eating and drinking.
16. On 13 July care staff identified a further pressure sore on Ms D’s sacral area. They updated her body map and applied cream to the affected area. The next morning care staff noted a third pressure sore which they dressed. At breakfast care staff reported Ms D was in pain and locking her mouth. The Care Provider called an ambulance and Ms D went to hospital.
17. The care records say care staff rang Ms D’s partner a number of times that morning but only managed to speak with her at midday after Ms D had gone into hospital.
18. Ms D died shortly after going into hospital. Mrs C says Ms D went into hospital dehydrated and with pressure sores. Mrs C says none of these were present two weeks earlier when she went into the care home.
19. Mrs C says the Care Provider failed to properly support Ms D and tell family members about a worsening in her health. This meant she lost an opportunity to say a final farewell to Ms D or take alternative action before Ms D went into hospital.
20. The Care Provider says it contacted Ms D’s partner on several occasions specifically:-
• following a bout of sickness;
• concerned about Ms D‘s eating and GP contact; and;
• about the SaLT assessment.

What should have happened

21. The following 2014 Regulations are relevant to this complaint:-
22. Regulation 12 – “Safe care and treatment”. This Regulation aims to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Providers must assess the risks to people's health and safety during any care or treatment. Guidance says providers must do what is reasonably practicable to mitigate risks.
23. Regulation 14 – “Meeting nutritional and hydration needs”. Providers must ensure people have enough to eat and drink to meet their nutrition and hydration needs and receive the support they need to do so. This is to reduce risks of malnutrition and dehydration.
24. Regulation 17 – ‘Good governance’. This regulation requires providers have systems and procedures in place to meet other regulatory requirements. Systems and procedures should assess, monitor, and mitigate any risks relating to the health, safety and welfare of people using services. Providers must also maintain accurate, complete, and detailed records for each person using the service.

Was there fault causing injustice?

25. The Care Provider could not do a face to face pre-admission assessment for Ms D at it was during a lock down period. The Care Provider was therefore reliant on information provided by Ms D’s partner. When Ms D entered the care home it realised Ms D had greater needs than it had first assessed. Care staff recorded a change in needs and made some amendments to Ms D’s care plan; it also completed daily care records.
26. The care records provide information about Ms D’s food and fluid intake. Staff also amended the care plan to reflect SaLT’s assessment about Ms D’s dietary needs but there is no record about how often staff should prompt Ms D with eating and drinking.
27. The Care Provider should have completed food and fluid charts to record Ms D’s intake as soon as it identified a concern. This would have provided a benchmark of the level of food and drink Ms D needed daily; and a record about whether she had managed to reach that level. The care plan should have also detailed how often staff should prompt Ms D with food and drink. I consider the failure to properly monitor Ms D’s food and drink is fault and not in line with Regulation 14.
28. Care staff acted when Ms D’s skin broke down. However, there is no evidence the Care Provider completed a risk assessment or updated the care plan about how care staff should treat Ms D’s skin until the day of her admission into hospital. This is not in line with Regulation 12. The Care Provider took advice from the GP but did not record what follow up action it took. This is not in line with Regulation 17.
29. Ms D has now died, and we cannot remedy any injustice the Care Provider’s actions may have caused her. From the care records it appears Ms D’s health declined rapidly over a short period of time. It is difficult to say now whether, but for the faults I have identified, Ms D would not have deteriorated as she did.
30. Due to the lack of recording Mrs C has the uncertainty of whether the Care Provider could have taken additional actions to prevent a deterioration in Ms D’s health.
31. Mrs C says the Care Provider failed to provide updates about Ms D’s health. As a result she lost an opportunity to decide whether to remove Ms D or make an urgent visit. I am unable to find fault in the actions of the Care Provider. The Care Provider appropriately provided updates to the given contact person.

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Agreed action

32. I have found service failure in the actions of the Care Provider which has caused uncertainty to Mrs C. The Care Provider has agreed to take the following actions to remedy the complaint:-
1. apologise to Mrs C for the uncertainty caused by the failures I have identified in paragraphs 27 and 28;
2. pay £250 to Mrs C for the uncertainty and anxiety caused by the Care Provider’s actions;
3. remind staff about updating care plans when there is a change in a resident’s needs;
4. review policy to provide a trigger for monitoring food and fluid;
5. remind staff about the importance of making contemporaneous records;
6. remind staff about recording second contacts when completing admission paperwork;
7. remind staff about recording and following up on advice from medical professionals including the GP so there is no doubt about the advice provided and followed by staff.
33. The Care Provider should complete actions (a) to (b) within one month of the final decision and (c) to (g) within three months of the final decision.

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Final decision

34. I have found the actions of the Care Provider caused Mrs C uncertainty about whether Ms D received the care she should have done when she was a resident at the care home. I have now completed my investigation and closed the complaint based on the agreed action above.
35. As I have found potential regulatory breaches, 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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Investigator's decision on behalf of the Ombudsman