Summary: Mrs X complained about poor communication and poor care provided to her father, Mr Y, in the three months prior to his death. The care provider upheld there was poor communication and apologised to Mrs X for this but did not accept there was poor care. The care provider was at fault. There was poor communication which caused Mrs X distress and uncertainty. There is no evidence of poor care. The care provider has agreed to pay Mrs X £150 as a symbolic payment in recognition of the distress and uncertainty caused by the poor communication.

The complaint

1. Mrs X complains about poor communication and poor care provided to her father, Mr Y, in Croft House Care Home (Somerset Care Ltd) in the three months prior to his death. She says despite signs his health was deteriorating, the home did not appropriately review his care needs. This led to poor care and his needs not being met.
2. The care provider has upheld there was poor communication and apologised to her for this. She wants the care provider to also accept there was poor care and provide a financial remedy for this and for the distress this caused.

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The Ombudsman’s role and powers

3. 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).
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

5. I read Mrs X’s complaint and spoke with her about it on the phone.
6. I made enquiries of the care provider and considered the information it sent me.
7. I considered our Guidance on Remedies
8. Mrs X and the Council had the opportunity to comment on the draft decision. I considered their comments before making a final decision.

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What I found

Background information

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 never fall. The fundamental standards include minimum standards for:
• Person-centred care
• Maintaining accurate and complete records
• Ensuring people are treated with dignity and respect
• Safe care and treatment
10. When investigating complaints about the standards of care in a care home, we consider if the 2014 regulations and the fundamental standards have been met. If they have not, we consider whether any identified faults have resulted in injustice.

What happened

11. In 2020, Mr Y lived in Croft House care home. He had a diagnosis of dementia.
12. In April 2020, Mr Y complained of feeling unwell. Care staff requested a GP visit and the GP prescribed antibiotics for a suspected infection.
13. Records show Mr Y slipped off his bed the next day and again 3 days later. Staff completed an incident form on both occasions and contacted Mrs X to inform her. Mr Y did not sustain any injuries.
14. The GP made four further visits to Mr Y in April 2020.
15. At the beginning of May, staff reviewed all Mr Y’s care plans. They did not include the family in this review. Staff had concerns Mr Y was suffering from breathing difficulties and the GP visited. The care records said staff contacted Mr Y’s family to inform them, but Mrs X says they did not.
16. District nurses reviewed Mr Y at the end of May. Mrs X says she was not informed or included in this review.
17. Weight charts show Mr Y lost 5kg in weight over four days at the end of May. The care provider says it reviewed this but could not explain this weight loss, as Mr Y continued to eat and drink and there were no other concerns. Despite the weight loss, his weight remained within healthy range.
18. At the beginning of June, Mr Y had a further fall. Staff found him sat on the floor in front of his bed. He told staff he had been walking across the room and went to sit on the edge of the bed, but ended up on the floor. He did not sustain any injuries and staff informed Mrs X about what had happened. The care home decided it needed to monitor Mr Y more closely and staff were informed of this at the next handover.
19. Staff reviewed and updated all of Mr Y’s care plans following this incident including his falls risk assessment. They told the family they had reviewed the plans but did not involve them in the review or show them the updated care plans.
20. In the middle of June, Mr Y told staff he felt low in mood and not very well. The GP visited and reviewed Mr Y. He prescribed medication for a suspected infection.
21. The GP visited again three days later to review Mr Y.
22. On 22 June, Mr Y reported feeling unwell. Staff did not inform his family of this. Whilst a relative was visiting, Mr Y began to choke whilst eating his lunch. The relative alerted care staff. Staff reported this was the first time it had happened. Care staff immediately implemented a soft diet and requested a GP visit. The GP visited and reviewed Mr Y later that evening.
23. Care staff reviewed his care plans again and updated them to reflect recent deterioration in Mr Y’s mobility and changes to the risk assessments. The home did not inform the family of this review or the changes made.
24. On 24 June, staff reported difficulty with moving and handling Mr Y overnight. They contacted the district nursing team to request a hospital style profiling bed and pressure-relieving equipment for Mr Y’s bed and chair. The district nurses told care staff the home needed to provide this. The home had a profiling bed, but it needed assembling and the staff member who could do this was off sick. Whilst working out how it could get the bed assembled for Mr Y, the care home provided a separate pressure cushion and mattress and fitted them to Mr Y’s bed and chair.
25. On 25 June, the district nurse visited and took Mr Y’s bloods. The GP also visited. The GP said they did not currently consider Mr Y needed end of life care.
26. The next day, the GP phoned the care home and said Mr Y was now deemed to be for end of life care. They told care staff they would be prescribing some medications and the district nurse would speak to Mr Y’s family about applying for continuing healthcare funding.
27. On 27 June, Mr Y slipped out of his chair. Records show staff checked on Mr Y at 7pm and he was sat in his chair, and when they next checked at 7.15pm, he was sat on the floor. Staff completed an incident form and informed Mr Y’s family. They reviewed his care plans and put additional equipment in place to alert staff if he tried to get up unaided and to reduce the risk of injury from any further falls.
28. On 28 June, care home staff assembled the profiling bed and provided it for Mr Y.
29. On 29 June, staff noticed Mr Y appeared to be gasping for air. This settled, but they began half hourly observations and requested a GP visit. The GP and the district nurse visited. The care provider says it contacted the family to update them after the GP visit and the records show a phone call to family made that day. Mrs X says she was not informed.
30. On 30 June, staff noted Mr Y seemed unsettled. The district nurse reviewed Mr Y that morning and administered some medication. Staff informed Mr Y’s family. The district nurse returned that evening and decided Mr Y was settled and did not need any further medication.
31. On 1 July 2020, in the early morning, staff noticed Mr Y had shallow breathing. They called the out of hours district nurse team who said a nurse would attend as soon as possible. Mr Y passed away an hour later.
32. Mrs X complained to the care home. She said she felt care staff should have noticed his deteriorating condition earlier and re-assessed whether he needed nursing care. The care home manager responded to her, but Mrs X was dissatisfied with the response.
33. She complained formally to the care provider in September. She complained about poor communication and poor care. She said:
• Care records were inaccurate and said care staff had contacted the family when they noticed Mr Y was having difficulty breathing in May, when they had not.
• Staff had not involved the family in reviews of Mr Y’s care plans or discussed any concerns about his increasing needs with them.
• Staff did not contact family on 22 June to tell them he was unwell, before they visited.
• Staff should have realised he was deteriorating earlier and taken steps to re-assess whether he needed an increased level of care.
• He should have been provided with a hospital bed earlier.
• Mr Y should not have been left unsupervised on 27 June, when he slipped out of his chair.
34. The care provider upheld her complaints about poor communication. It acknowledged its records from May were inaccurate and said care staff had contacted the family about Mr Y’s breathing difficulties when it had not. It accepted it should have involved the family in the reviews of Mr Y’s care plans and communicated more with them about his deteriorating health. It apologised to her for the poor communication and said it had learnt from the complaint and had arranged staff training and other service improvements in response.
35. It did not uphold her complaints about poor care. It said the care records did not support this and although it accepted when Mr Y slipped from his chair this must have been upsetting, staff were sitting him out for short periods for beneficial reasons. It said in the few days when the need for a profiling bed was identified but not available, staff appropriately cared for Mr Y on his divan bed which had pressure relieving equipment in place.
36. Mrs X remained dissatisfied and brought her complaint to us.

Analysis

37. The care provider has upheld that there was poor communication. I agree with this finding. Although there is evidence of regular phone calls to the family, the evidence shows the care home:
• reviewed Mr Y’s care plans at least three times between April and June 2020 but did not involve the family in these reviews or tell them of the changes.
• could see his needs were increasing in June, and appropriately involved the GP and district nurses. However, there is no evidence this deterioration was discussed or communicated to Mr Y’s family.
• did not contact the family when Mr Y was having breathing difficulties in May, even though the records say it did.
• did not contact the family on 22 June to advise them he was feeling unwell and may not be well enough for a visit.
38. The poor communication was fault. The care provider has apologised to Mrs X for this. However, the poor communication caused Mrs X significant distress. Mr Y was deteriorating rapidly through June and the lack of communication caused Mrs X uncertainty about the status of Mr Y’s health and whether he was receiving appropriate care. The situation was exacerbated by the COVID-19 pandemic, which restricted Mrs X’s ability to visit and is likely to have added to the distress and uncertainty caused. Although the care provider has apologised, it should make a symbolic payment to Mrs X in recognition of the distress caused to her at a difficult time. I have made a recommendation below, in line with our guidance on remedies.
39. The care provider has taken steps to improve its service by providing further communications and skills training for staff. This is an appropriate action.
40. The records do not show evidence of poor care. The evidence shows the care home:
• Regularly reviewed Mr Y’s care plans and updated them according to his changing needs;
• Appropriately requested GP visits and district nursing input, when this was indicated;
• Responded appropriately after Mr Y had difficulty swallowing by immediately implementing a soft diet and requesting a GP review;
• Provided Mr Y with pressure relieving equipment and appropriately cared for him using this equipment, prior to the installation of the profiling bed. There is no evidence the delay in providing the profiling bed impacted on the quality of care Mr Y received; and
• Made a clinical decision to sit him out in his chair at the end of June, which I do not find unreasonable given the circumstances and the risks of prolonged bed rest. After the incident, care staff appropriately reviewed the risk assessments.

There is no evidence of poor care, so Mr Y was not caused any injustice. The care provider was not at fault.

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Agreed action

41. Within one month of the final decision, the care provider will offer Mrs X £150 as a symbolic payment in recognition of the distress and uncertainty caused to her by the poor communication. It will pay this to Mrs X if she accepts the offer.

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Final decision

42. I have completed my investigation. I have found fault and the care provider has agreed action to remedy the injustice caused.

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Investigator's decision on behalf of the Ombudsman