Summary: Mr X complained Porthaven Care Homes No 3 Limited (the Care Provider) failed to provide adequate care to his wife, Mrs X during her respite stay for ten nights in the autumn of 2020. We found the Care Provider failed to identify an illness Mrs X was suffering from and to administer medicine in good time. We also found fault in the Care Provider’s record keeping. The Care Provider agreed to apologise to Mr X and pay him £150 to recognise the uncertainty and distress caused to him.

The complaint

1. Mr X complained Porthaven Care Homes No 3 Limited (the Care Provider) failed to provide adequate care to his wife, Mrs X during her respite stay for ten nights in the autumn of 2020. Mr X says the Care Provider failed to identify injuries Mrs X suffered following a fall and failed to identify an illness she was suffering from. Mr X states Mrs X suffered unnecessary harm, distress and neglect during her stay with the Care Provider. He said the matter has caused him significant ongoing upset and 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. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
3. 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)
4. 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.
5. We normally expect someone to complain to the Care Quality Commission (CQC) about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended)
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. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the CQC, we will share this decision with CQC.

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How I considered this complaint

8. I read the documents provided by Mr X and discussed the complaint with him and Ms C, (Mrs X’s regular carer), on the telephone.
9. I read the documents submitted by the Care Provider in response to my enquiries.
10. I considered the comments on my first draft decision provided by Mr X and the Care Provider.
11. Mr X 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

The law

12. 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.
13. Regulation 12 says care and treatment must be provided in a safe way and prevent avoidable harm or risks. It states the care provider must assess health and safety risks and do all they can to mitigate any risks. This also includes using equipment that is in full working order and the proper supply and management of medicines.
14. Regulation 14 sets out people must have adequate nutrition and hydration to sustain good health. It states people must be provided with appropriate food and drink and any support they may need to achieve adequate nutrition.
15. Regulation 17 states providers must securely maintain accurate, complete and detailed records about each person using their service.

Capacity

16. The Mental Capacity Act code of practice sets out capacity is the ability to make a decision. Someone who lacks capacity cannot make a particular decision, or take a particular action, for themselves at the time the decision or action needs to be taken. Capacity is time and decision dependant, which means someone may have capacity to decide whether to eat a meal but not where to live.

Urinary Tract Infection

17. The NHS states a urinary tract infection (UTI) is an infection of the urinary tract including bladder, urethra or kidneys. The symptoms of a UTI may include blood in the urine, increased incontinence and changes in behaviour such as agitation.

What happened

18. In September 2020 Mr X arranged respite care for Mrs X at the Care Provider’s care home, Upton Mill, for ten nights.
19. Mr X and Ms C, along with Mrs X’s daughter provided information to the Care Provider as part of Mrs X’s pre-admission assessment. The pre-admission assessment recorded Mrs X did not have capacity to consent to her care and accommodation. It recorded Mrs X suffered from a number of conditions and had a history of falls.
20. The pre-admission assessment stated Mrs X wore a wig day and night. It recorded Mrs X took medication to control her diabetes, was prone to both constipation and UTIs and wore an incontinence pad at night for comfort. The assessment listed Mrs X’s medications and their prescribed doses and frequency. Amongst them it recorded the provider should administer medication for constipation, once daily in the evening.
21. The Care Provider produced a care plan and risk assessments based on the pre-admission assessment. It outlined Mrs X’s needs and how it would meet those needs. The documents outlined Mrs X:
• did not have the capacity to make decisions about medication, healthcare and treatments;
• was at high risk of falls and two sensor mats would be placed in her bedroom to alert staff if she tried to move without assistance;
• food intake needed to be monitored and she had fortified milkshakes available if required;
• took medication twice a day to manage her diabetes and needed her blood sugar levels monitoring on the blood glucose chart twice a week;
• was at medium risk of constipation and was prescribed a laxative to take as and when required to manage this; and
• required one-to-one care in addition to all other care for six hours per day;

Falls

22. Mrs X’s care records recorded she fell three times. There are no records to indicate that the sensor mats activated on the first two falls. The Care Provider did not increase Mrs X’s risk of falls score or identify any extra actions or changes to the care plan to mitigate the risks.
23. On the final day of Mrs X’s stay, the records indicate Mrs X fell for a third time. There is no record of the sensor mat activating. The Registered Nurse recorded she completed a full body examination and identified a superficial laceration on Mrs X’s arm. The Nurse checked Mrs X’s vital signs five times over the next hour which she recorded as within Mrs X’s normal limits. The Care Provider phoned Mr X and told him of the fall and superficial injury to Mrs X’s arm. Two hours after Mrs X’s fall Mr X and Ms C arrived to take her home after her respite stay. The Care Provider did not provide Mr X or Ms C with any further information about the fall or subsequent treatments.
24. The Care Provider completed an accident report. This recorded an action for the Care Provider to remind staff to ensure sensor mats were in an appropriate position and to check they activated and worked before leaving a resident’s room.

Diabetic care

25. The Care Provider’s food intake chart shows it offered Mrs X three meals per day for most of her stay with occasional snacks. The chart shows Mrs X ate little.
26. Mrs X’s medicine administration record (MAR) and progress notes show the Care Provider gave her diabetic medication as prescribed and measured her blood glucose levels on four occasions.

Urinary Tract Infection

27. The activity of daily living (ADL) record shows a staff member identified a blood stain on Mrs X’s incontinence pad on day five of her stay. The staff member told the registered nurse. There is no further reference to the blood stain within the Care Provider’s records. The ADL also shows Mrs X became more incontinent during her stay.
28. The Care Provider said it used a national early warning score to monitor Mrs X’s health during her stay. It completed the score on day five due to Mrs X’s fall, not in relation to the blood stain. The score showed Mrs X had a low clinical risk. The Care Provider completed this again after Mrs X’s final fall on day eleven and did not note any areas of concern. The records also show the Care Provider monitored Mrs X’s temperature and oxygen levels twice a day throughout her stay and they remained stable.
29. The behaviour charts recorded any incidents of behaviour which were worthy of note or needed extra support. Mrs X’s behaviour chart shows there was a change in her behaviour from day seven of her stay. Mrs X was aggressive and threatening to staff members.

Constipation

30. The Care Provider recorded Mrs X did not open her bowels between the first day of her stay and day nine. On day six the Care Provider administered medication to Mrs X. The medication was ineffective, the Care Provider administered it twice more on days eight and nine and it was effective on day nine.
31. Mrs X’s MAR chart recorded the instructions for the medication as ‘take one or two sachets…daily as needed to treat constipation’. The purpose of this was to relieve symptoms of constipation and to maintain regular bowel movements.

One-to-one care

32. The information held on the Care Provider’s leisure and wellness reports, activities chart and progress notes show Mrs X received some one-to-one care during her stay. The records do not specify the amount of time spent in each activity. On three days there are no record of any one-to-one activities. On day three a staff member spent 40 minutes with Mrs X completing a crossword, and on day ten staff spent two and a half hours with Mrs X.

The complaint

33. Mr X said on Mrs X’s return home he and Ms C were concerned about her health. The following morning Mr X says Ms C removed Mrs X’s wig and discovered dried blood within it. Mr X says Mrs X had a large bruise on the right side of her head and a large swelling, bruise and broken skin on the left side of her head. Mr X says Mrs X also had injuries to other parts of her body. Mrs X was taken to hospital by ambulance where Mr X said she was diagnosed with a bleed on the brain, as a result of the head injuries, and a UTI.
34. Ten days after Mrs X left the care home Mr X complained to the Care Provider. He complained that:
• Mrs X had fallen three times during her stay despite the Care Provider being aware she was at high risk of falls;
• the Care Provider had failed to identify Mrs X’s head injury following her third fall;
• Mrs X had not showered or bathed during her stay and the Care Provider only gave her flannel washes;
• the Care Provider failed to identify Mrs X was suffering from a UTI;
• the Care Provider did not provide Mrs X with a regular dose of laxative to relieve constipation;
• Mrs X did not receive the level of social interaction and emotional support she required;
• the Care Provider did not monitor Mrs X blood sugar levels in line with diabetic guidance when she was not eating well; and
• the telephone lines had been poor and made it very difficult for Mrs X to speak with her family during her stay.
35. Mr X stated because of her stay at the care home Mrs X had physical and mental injuries.
36. The Care Provider responded to Mr X’s complaints. It stated it was aware of Mrs X’s risk of falling. It said it had put control measures in place including a sensor mat in her room to alert staff when she was trying to move, ensured regular staff contact and placed her in a room opposite the nurse’s station so they could hear her call out. It had reviewed Mrs X risk assessment each time she fell. If she had stayed after her final fall, it would have used a passive infrared sensor in her room. It said the control measures had worked effectively until the final day of Mrs X’s stay.
37. In relation to Mrs X’s injuries, it said the Registered Nurse had completed a full body check following Mrs X’s third fall. It stated Mrs X was emotional and distressed and had refused to let her touch or move her wig. The Nurse had checked Mrs X’s head over her wig. She then monitored her vital signs every 15 minutes for the next hour which did not suggest Mrs X needed any further care.
38. In relation to the UTI the Care Provider stated it monitored Mrs X’s vital signs twice daily. It completed extra screening for early indication of illness twice on the day the blood stain was found on Mrs X’s incontinence pad. It said none of those observations suggested Mrs X was suffering from an illness. It had also monitored Mrs X’s behaviour and did not see any sudden or unexpected changes in behaviour that indicated an illness.
39. In relation to constipation the Care Provider stated it had administered the medication to Mrs X only when it was required. It said there were no clinical indicators Mrs X was suffering from constipation. It stated the laxative was prescribed to be administered as required rather than as a regular medication.
40. In relation to social interaction the Care Provider stated its records showed there were many interactions between Mrs X and staff members every day. It said Mrs X received the paper each day and would often read it alone or with staff.
41. In relation to food intake and diabetes care the Care Provider stated it monitored Mrs X’s food intake for the first three days to ensure it understood her normal eating patterns, after which it partially recorded Mrs X’s food. It stated it offered Mrs X snacks between meals some of which were recorded in other notes. Mrs X was administered medication in line with her prescription to manage her diabetes. It said it tested Mrs X’s blood sugar level four times during her stay which was within normal ranges.
42. In relation to telephone contact between Mrs X and her family the Care Provider acknowledged there had been some issues with the telephone system. It apologised for the frustration it had caused.
43. The Care Provider stated it was confident in the quality of the care it provided to Mrs X. However, it intended to provide additional guidance to its staff on the importance of recording activities and snacks in more detail. It stated staff would also receive further education in recording on accident forms and the need to share appropriate information with next of kin.
44. Dissatisfied with the Care Provider’s response Mr X escalated his complaint with the Care Provider. He raised the points about Mrs X’s falls, the amount of food Mrs X ate and her diabetic care and social interactions.
45. The Care Provider responded to Mr X’s second complaint and reiterated its previous response which it said was comprehensive.
46. Mr X made a stage three complaint to the Care Provider. Mr X stated he had received neither an apology nor an acceptance of the failings in care. Mr X stated the Registered Nurse did not perform a full body check on Mrs X and had falsely recorded she had done so. Mr X stated the Care Provider had failed to identify Mrs X’s head injuries.
47. The Care Provider sent a response to Mr X the following month. It stated it gave Mrs X the minimum restrictive support to afford her privacy which was in line with the statutory guidance. It stated Mrs X’s falls were related to her health conditions and not due to negligent care. It confirmed the bruises identified on Mrs X were due to the falls at the care home. It stated the Nurse completed a primary assessment after the third fall and excluded a head injury. It said Mrs X refused to remove her wig and to respect her wishes the Nurse had not removed it. It stated if Mrs X had been in a life-threatening situation, it would have made a best interest decision to assist her. It upheld its previous responses to Mr X on the other points.
48. In response to my enquiries the Care Provider submitted statements from the Registered Nurse and the Registered Care Manager that detailed their actions following Mrs X’s third fall. The Nurse’s statement records she had difficulty examining Mrs X’s head as she would not remove her wig. The Manager’s statement recorded Mrs X did not want her wig moved or touched. They said the Nurse asked Mrs X for her consent to palpate her head over the wig.
49. In response to my enquiries the Care Provider stated Mrs X was not assessed as needing one-to-one care during her stay and it had not been requested.
50. In relation to the sensor mats the Care Provider provided evidence the sensor mats were regularly checked and found to be in good working order. The Care Provider stated the mats did not activate after the first two falls as on those occasions Mrs X slipped from her chair. It stated the sensor mats were not placed directly under the chair as they would be activated by foot movement unnecessarily. It stated that Mrs X did not cross the sensor mat when walking to the bathroom and therefore it did not activate.

My findings

Falls

51. The Care Provider was aware of Mrs X’s risk of falls. It introduced control measures to reduce the risk, including sensor mats. The sensor mats did not activate for the first two falls as Mrs X had slipped from her chair and not moved across a sensor mat. On the third fall Mrs X was able to move from her bed without triggering an alarm. Mrs X left the care home around two hours later and as such the Care Provider was not able to introduce any further control measures to help prevent a reoccurrence. The records show that the sensor mats were regularly tested and in good working order. The Care Provider had appropriate control measures in place to reduce the risk of falls. There was no fault in the Care Provider’s actions.
52. After Mrs X’s third fall, the contemporaneous record specified a full body examination was conducted and did not record Mrs X declined to remove her wig. The Care Provider later said Mrs X refused to remove her wig for staff to check her head and they had palpated her head over her wig. The failure to keep accurate and complete records means the Care Provider failed to act in line with regulation 17 of the fundamental standards and is fault.

Diabetic care

53. Mrs X’s care plan stated her food intake should be monitored. The Care Provider stated it monitored Mrs X’s intake for the first three days and then partially recorded it as there was no clinical need to continue. The Care Provider administered Mrs X’s diabetic medication and tested her blood glucose level in line with the care plan and her prescriptions. I do not find there was any fault in the Care Provider’s actions in relation to Mrs X’s diabetic care.

Urinary tract infection

54. The Care Provider was aware Mrs X was prone to UTIs. The records show there was blood in her urine, increased incontinence and changes in Mrs X’s behaviour. The symptoms, combined with Mrs X’s history of UTIs were sufficient to indicate further investigation was needed. When Mrs X was admitted to hospital the following day she was diagnosed with a significant UTI. On the balance of probabilities Mrs X had the UTI in the latter days of her stay at the care home. The Care Provider did not make any investigations and that was fault and not in line with regulation 12 of the fundamental standards.

Constipation

55. Mr X and Ms C told the Care Provider Mrs X took medication every evening to avoid the risk of constipation. The MAR chart stated the medication should be administered as one or two daily as needed. The daily charts recorded Mrs X did not have a bowel movement for six days. On the balance of probabilities the Care Provider should have administered the medication earlier. Its failure to do so was fault.

One-to-one care

56. Mrs X’s care plan specified she needed six hours one-to-one care in addition to all other care. It is not clear what the intended purpose of the one-to-one care was, and the Care Provider said this was an error in Mrs X’s care plan in its response to my enquiries. The records do not reflect Mrs X received that care. On the balance of probabilities, I find Mrs X did not receive the one-to-one care specified in her care plan. As the record was made in error and not amended, this was not in line with regulation 17 of the fundamental standards and was fault.
57. I cannot say what injustice this caused to Mrs X. However, it caused Mr X distress as Mrs X did not receive the level of care Mr X felt she needed.

Injustice arising from the fault

58. Mrs X has now died. Where a person has died, and we have found fault which may have led to injustice, we will not normally seek a remedy in the same way we might for someone who was still living. Therefore, I have not considered the effect of the fault I have identified on Mrs X.
59. However, Mr X has been caused distress and uncertainty in relation to whether Mrs X experienced avoidable harm in relation to the injury from her fall, urinary tract infection, one-to-one care and failure to provide her with medication for her constipation when required. The Care Provider should make a token payment to acknowledge this injustice.

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Agreed actions

60. Within one month of this decision the Care Provider agreed to apologise to Mr X for the distress and uncertainty caused to him by the poor care Mrs X received during her stay.
61. Within one month of this decision the Care Provider agreed to pay Mr X £150 to recognise the distress and uncertainty caused to him.
62. The Care Provider agreed to provide us with the evidence it has carried out the additional training with relevant staff members that it identified in its complaint response, outlined in paragraph 43. If it has not completed this training it agreed to do so within one month of this decision and provide us evidence it has done so.
63. Within one month the Care Provider agreed to remind relevant staff members of the importance of maintaining accurate, complete and detailed records. It will provide us with evidence that it has done so.

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Final decision

64. I have completed my investigation. I have found fault leading to injustice and the Care Provider has agreed to my recommendations to remedy that injustice.

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Investigator's decision on behalf of the Ombudsman