Summary: Mr X complained about the poor care his late father, Mr Y, received from Barchester Healthcare Homes Limited. The Care Provider was at fault as it failed to recognise Mr Y was seriously ill and did not take appropriate action. There were also errors in communication and record keeping and Mr Y’s individual needs were not considered. The Care Provider has agreed to apologise and pay £300 to Mr X and the family to acknowledge the distress caused by the poor care Mr Y received. The Care Provider will also review staff knowledge and understanding in relation to the poor care which was delivered.

The complaint

1. Mr X complained about the respite care his late father, Mr Y, received from Barchester Healthcare Homes Limited (the Care Provider). He said it failed to meet Mr Y’s care needs and it failed to recognise and take action when Mr Y was seriously ill. Mr X said the Care Provider did not properly consider the impact this had on him and the family and he was not confident it had learned lessons from the matter. Mr X said it caused him and the family distress.

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. (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. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (section 26A or 34C, Local Government Act 1974)
5. 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)

Back to top

How I considered this complaint

6. I considered the information provided by Mr X and the Care Provider.
7. I considered the Council’s safeguarding investigation documents provided by the Council.
8. I considered our Guidance on Remedies.
9. Mr X and the Care Provider had the opportunity to comment on the draft version of this decision. I considered their comments before making a final decision.
10. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Back to top

What I found

Legislation and Guidance

11. 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) is the statutory regulator of care services. It has issued guidance on how to meet the fundamental standards below which care must never fall:
• Regulation 9 sets out care providers must make sure each person receives appropriate person-centred care and treatment that is based on an assessment of their needs and preferences.
• Regulation 10 requires care providers to make sure people using the service are treated with dignity and respect at all times while they are receiving care and treatment.
• Regulation 17 sets out guidelines for good governance. As part of this regulation, care providers must securely maintain accurate, complete and detailed records in respect of each person using the service.
12. 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)

What happened

13. Between January and February 2020, Mr Y received short-term respite care at the Care Provider’s Care Home, Westwood House. Mr Y had several health problems including hearing loss. The Care Provider assessed Mr Y as requiring assistance with personal care including dressing and continence care. Mr Y was able to independently mobilise with the support of a walking frame. He was also able to independently eat and drink with a normal diet. It was noted in Mr Y’s admission document that Mr Y had a poor swallow and required thickened fluids. It was also noted Mr Y had a hearing aid in both of his ears.
14. Mr X and the family wanted Mr Y to have a room on the standard nursing floor so he could be around residents similar to himself. However, there was only capacity available on the dementia floor. Mr Y was given a room on the dementia floor but Mr X and the family asked the Care Provider if Mr Y could still spend the majority of his time on the standard nursing floor and have his meals there. The Care Provider agreed to this.
15. During Mr Y’s stay at the Care Home, Mr X and the family visited him. Mr X said on several occasions they found Mr Y alone in his room or on the dementia floor. Mr X said the family questioned the Care Provider why Mr Y was not spending his time on the standard nursing floor as it had previously agreed. They explained to the Care Provider that Mr Y had his lunch on the standard nursing floor before and he had really enjoyed it. The Care Provider apologised to the family and said it would ensure staff collected Mr Y from his room every morning so that he could have his meals downstairs. During this conversation, the Care Provider made the family aware staff had seen Mr Y walking without his frame. The family responded and said staff needed to prompt Mr Y to use the walking frame. The Care Provider said it would let the staff know.
16. Mr X said the family found on one occasion Mr Y was agitated and confused. The family realised Mr Y could not hear. They changed the battery of Mr Y’s hearing aid and he was able to hear again.
17. On another day when the family visited Mr Y, he was wearing his pyjamas under his day clothes. The family said it was difficult for Mr Y to use the toilet as he had too many layers of clothing on. The family raised their concern with the Care Provider and it said it would look into this and get back to them. The Care Provider did not discuss this with the family again.
18. Mr X and the family decided to collect Mr Y the day before his planned discharge date. They discussed this with the Care Provider and checked that Mr Y would be ready with his belongings packed. However, when the family arrived at the Care Home, they said Mr Y’s clothes were carelessly put into his bag, some of his clothes and toiletries were still out in the room and some of his belongings were missing. The family also said they found items of clothing in the wardrobe which did not belong to Mr Y.
19. When the family approached Mr Y, they said he was slumped in a chair in the hallway. The family said Mr Y did not look well and was unresponsive. They said they were informed by staff Mr Y had an episode of faecal incontinence during the night and he was sat in the chair in the hallway because his room was being cleaned up. Staff continued and said Mr Y had refused lunch and he had been sleepy and stumbled as he walked. Mr Y’s family said staff had not taken his vital signs. The family said they called NHS 111 for advice and during this time, the staff on duty took Mr Y’s vital signs and the family relayed this information to the NHS 111 service. Upon receiving this information, NHS 111 requested for an ambulance to be dispatched however informed Mr Y’s family it could take up to four hours for the ambulance to arrive. Mr Y’s family decided to take Mr Y to his home and asked for the ambulance to be re-directed to his home address. The ambulance arrived and Mr Y was admitted into hospital. At hospital, Mr Y was diagnosed with a suspected heart attack and sepsis. Ten days after his admission to the hospital, Mr Y died.

The complaint and the complaint response

20. Shortly after Mr Y died, Mr X and his family complained to the Care Provider that:
• Mr Y was not taken to the standard nursing floor as it had agreed.
• Staff had seen Mr Y walking without his walking frame and staff did not remind him to use it.
• Mr Y’s hearing aid was not working which caused him to be agitated and confused and staff did not notice this or check to see if the batteries needed changing.
• Staff had dressed Mr Y with his day clothes over his pyjamas; and
• Mr Y’s belongings were not packed and ready for his departure.
21. Above all, Mr X and the family wanted to know what happened on the day they went to collect Mr Y. They wanted to know why the staff failed to recognise Mr Y was seriously ill, why staff did not take or record any observations of Mr Y and why the Care Provider did not inform them there was a change in Mr Y’s condition.
22. The Care Provider responded to Mr X and the family. The Care Provider said it was recorded in Mr Y’s care notes that staff should support him with going to the standard nursing floor daily. It continued and said Mr Y was reluctant to go to the standard nursing floor and unfortunately, staff did not inform Mr Y’s family of this. Mr Y’s care notes did not reflect what action staff took to address Mr Y’s reluctance and they did not show if staff shared this with senior management so that it could be discussed with the family to implement strategies.
23. The Care Provider said Mr Y became unsettled when he went to the standard nursing floor. He wanted to go back to his room and watch television. It said there was no evidence Mr Y was unhappy being in his room. The Care Provider acknowledged that staff did not escalate this matter with senior management.
24. The Care Provider said staff were aware to remind Mr Y to use his walking frame and often did remind him. It referred to Mr Y’s care records and said there was only one occasion where Mr Y refused to walk with his walking frame and staff made many attempts to remind him to use it. The Care Provider acknowledged there were no further strategies noted in Mr Y’s care plan for staff to use if Mr Y refused to use his walking frame however, it said Mr Y did not come to harm when he was seen mobilising without it.
25. The Care Provider explained Mr Y dressed himself over his pyjamas. It apologised to Mr X and the family for not following this up with them before, as it said it would.
26. The Care Provider said staff were aware of Mr Y’s discharge date and apologised to Mr X and the family for not having his bags packed and for the lack of care given to his belongings.
27. The Care Provider apologised to Mr X and the family for the upset it caused when they went to collect Mr Y from the Care Home. It acknowledged it was not proactive in seeking advice from the GP or from NHS 111 at the time staff noticed Mr Y’s condition had changed. It said it had a policy and process in place to manage clinical deterioration of a resident and staff did not follow this effectively. It explained the staff on duty at the time said they did take observations before the family arrived at the Care Home but they did not record the observations they took. The staff on duty said there was nothing alarming in the observations they took but the Care Provider cannot say what they indicated as there was no record of them. The Care Provider said it was noted Mr Y was sleepy and chesty with secretions which indicated he should have been observed. It continued and said it was aware the Deputy Manager advised the staff on duty to take observations and to call the GP however it was Mr Y’s family who called NHS 111. The Care Provider said it was not acceptable that the family had to seek advice and instead, the staff on duty should have called the GP. The Care Provider said whilst it acknowledged staff should have sought medical advice at the onset of Mr Y’s symptoms, it noted the medical staff at NHS 111 arranged for an ambulance to attend within a four-hour time frame. It said it could not determine if staff had responded to Mr Y’s symptoms sooner, the outcome would have been different for Mr Y as NHS 111 did not feel it was necessary for an emergency ambulance.
28. The Care Provider concluded its response and said it had received support and training organised through the Council in recognising and responding to a deteriorating resident and emergency response. All nurses at the Care Home had completed this training and had ongoing support by its Clinical Development Nurse. The Care Provider said it would continue to engage in further training offered by the Council and it would review its own policy and process in recognising and responding to a deteriorating resident. It added it would be conducting supervision with staff who attended to Mr Y on his last day at the Care Home. This was so they would know how to appropriately respond to clinical deterioration in adults in line with policy, procedures and best practice guidance.

The Council’s safeguarding investigation

29. Mr X and the family contacted the Council’s safeguarding team and made it aware of their concerns of Mr Y’s stay at the Care Home. The Council conducted a safeguarding investigation and its primary focus was about how the Care Provider responded to Mr Y’s deterioration in health towards the end of his stay.
30. The Council said staff had identified Mr Y appeared unwell on the morning of his discharge date however there was no indication staff had taken action until Mr Y’s family visited and raised their concerns. In addition, when staff did respond to Mr Y’s change in health and the family’s concerns, they did not do this in line with best practice and left important decisions to the family to make who were not clinically trained and who found this highly stressful.
31. The Council added although the Care Provider was not responsive to Mr Y’s deterioration in health, it could not determine if this contributed to Mr Y’s outcome. It recognised that the decision made by the medical staff at NHS 111 did not indicate Mr Y should have been taken into hospital sooner. However, the Council identified the confused manner in which the staff on duty reported Mr Y’s deterioration to NHS 111 and said this could have affected evidence-based decision making.
32. The Council concluded on the balance of probability, the concerns were substantiated. There were errors in clinical care and decision making in the way the Care Provider responded to the deterioration in Mr Y’s health.
33. The Council agreed with the recommendations made in the Care Provider’s complaint response. It asked the Care Provider to provide evidence to the Council that the clinical training had been completed. It added that the training should be audited regularly by the Care Provider so that staff knowledge and skills were examined to ensure best practice was further embedded. The Care Provider did this and the Council was satisfied the recommendations were implemented.
34. During the safeguarding investigation, the Council also considered the family’s concerns about the general quality of care Mr Y received and said they indicated shortfalls in the quality of the care which affected the family’s trust in the Care Provider. It said the concerns indicated it was likely staff’s observations of Mr Y were limited and staff did not consider Mr Y’s specific personal needs or preferences. It added that the gaps in the communication between staff and senior management could have contributed to increased risk or oversight in Mr Y’s care.
35. The Council also commented that Mr Y’s care records had limited information and were incomplete on some days. In addition, the Council noted in Mr Y’s admission document, it stated Mr Y had a poor swallow and required thickened fluids and it was not indicated in Mr Y’s fluid charts if staff had consistently followed this.
36. After the Council closed its safeguarding investigation, Mr X and the family remained unhappy as they felt the Care Provider did not fully consider the impact this matter had on them. Mr X and the family complained to us.

Back to top

Findings

37. The Care Provider failed to recognise and respond appropriately when Mr Y’s health began to deteriorate. This was fault. In its response to Mr X and the family’s complaint, it acknowledged its clinical error and decision making in how it responded to Mr Y. As part of its recommendations, the Care Provider said all staff at the Care Home had completed training in relation to recognising and responding to the deteriorating resident and emergency response with support from the Council. This is what we would expect it to do.
38. As part of the Council’s safeguarding investigation, the Council reviewed this recommendation and was satisfied the Care Provider had implemented it.
39. In addition to the above, the Care Provider said it would review its own policy and processes in recognising and responding to the deteriorating resident and it would carry out a supervision with staff who attended to Mr Y on his last day. This is what we would expect it to do.
40. Mr X and the family were not happy with Mr Y being left on the dementia floor and in his room alone. The Care Provider explained Mr Y was reluctant to go to the standard nursing floor and he preferred to stay in his room and watch TV. The Care Provider however, recognised staff did not share this with Mr Y’s family or senior management so that further strategies could have been discussed and implemented. This was fault.
41. The Care Provider also noted staff did not record what actions they took in response to Mr Y’s reluctance to go to the standard nursing floor or to leave his room. In addition, it was not recorded in Mr Y’s admission form and contract with the Care Provider that Mr X would be escorted to the standard nursing floor daily although this was the agreement. This was fault and demonstrated poor record keeping which was not in line with the fundamental standards of care.
42. Mr X and the family wanted to know why Mr Y was seen by staff walking without his frame. The Care Provider responded that staff were aware they had to remind Mr Y to use his walking frame when he mobilised however he often refused. The Care Provider acted appropriately when Mr Y was reluctant to use his frame. I did not investigate this further as there was no evidence Mr Y was caused harm because of this.
43. Mr X and the family said on one occasion they visited, they found Mr Y agitated and confused and noticed this was because his hearing aid had run out of battery. They complained staff had not taken notice of this. In Mr Y’s admission form it detailed Mr Y had a hearing aid in both ears. There was nothing written in Mr Y’s care documents which instructed staff to check if his hearing aids were operating or to be aware of any signs he was struggling. This was fault and may have contributed to Mr Y being agitated and confused.
44. The Care Provider explained in its complaint response to Mr X and the family that Mr Y had dressed himself in his day clothes over his pyjamas. It recognised it failed to explain this earlier to Mr X and the family. This was fault. Again, this demonstrated poor communication between the Care Provider and Mr X and the family.
45. The Care Provider was aware of Mr Y’s discharge date however it did not pack up his belongings. The Care Provider recognised the lack of care its staff gave to Mr Y’s belongings. This was fault. Staff failed to follow instruction for Mr Y to be ready for his discharge and staff failed to take care of his belongings.
46. The Council noted in its safeguarding investigation there were gaps in Mr Y’s care records and it was not clear if staff provided Mr Y with thickened fluids as indicated in his admission document. I also reviewed Mr Y’s care records which included his food and fluid records and wellbeing observation charts. Apart from it not being clear if staff gave Mr Y thickened fluids, the information did not indicate a concern in the care Mr Y received. However, I note there were days which were not accounted for and some information was incomplete. This was fault and again, indicated poor record keeping which was not in line with the fundamental standards of care.
47. As Mr Y has died, I cannot recommend a remedy for the injustice these faults caused him. However, these faults caused distress to Mr Y’s family and left them with a sense of uncertainty over whether Mr Y was properly cared for during his respite stay.

Back to top

Agreed actions

48. Within one month of the final decision, the Care Provider has agreed it will:
• Provide a written apology to Mr X and the family to acknowledge the distress the faults detailed above have caused them.
• Make a symbolic payment to Mr X and the family of £300 to acknowledge the distress caused by the poor care Mr Y received at the Care Home.
49. Within three months of the final decision, the Care Provider has agreed it will provide evidence it has carried out the recommendations set out in the complaint response relating to reviewing its own policy and processes in recognising and responding to the deteriorating resident and supervision of relevant staff who attended to Mr Y on his last day at the Care Home.
50. Within three months of the final decision, the Care Provider has agreed it will provide training/guidance to staff in relation to:
• communicating effectively with senior management and with relatives when there are concerns about a person who uses the service.
• good record keeping and the impact poor record keeping has on the person receiving the care.
• ensuring needs assessments are accurate, they properly record the individual needs of a person using the service and ensure the care is being delivered.
51. It should provide the Ombudsman with evidence it has done this.

Back to top

Final decision

52. I have now completed my investigation. There was evidence of fault causing an injustice which the Care Provider has agreed to remedy.

Back to top

Investigator's decision on behalf of the Ombudsman