Summary: Mrs Y complained about the quality of care provided to Mr X by Shire House, on behalf of the Council. We have found fault by Shire House in its care of Mr X, in failing to keep accurate records, properly monitor his food and fluid intake and assess the risk to his health or the need for further medical intervention. This fault caused injustice which the Council has agreed to remedy by making a payment to Mrs Y to reflect the distress, time and trouble caused to her and her family, apologising and providing evidence of the action taken to improve Shire House’s service.

The complaint

1. The complainant, who I am calling Mrs Y, complains about the quality of care provided to her late brother, Mr X, by his residential care provider, Shire House (SH), on the Council’s behalf, in the period before his admission to hospital in August 2020.

2. Mrs Y says SH failed to:

• monitor Mr X’s food and fluid intake;
• note the serious deterioration in Mr X’s condition in the days before his admission to hospital: and
• escalate Mr X’s care appropriately or obtain medical assistance sooner to prevent the further deterioration in his condition and his death a few days after admission to hospital.

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The Ombudsman’s role and powers

3. 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)
4. 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)
5. 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

6. I spoke to Mrs Y, made enquiries of the Council and read the information Mrs Y and the Council provided about the complaint.
7. I invited Mrs Y and the Council to comment on a draft version of this decision. I considered their responses before making my final decision.
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

What should have happened

9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards registered care providers must achieve. The CQC, as the statutory regulator of care services, has issued guidance on how to meet these standards below which care must never fall.
10. We consider the 2014 Regulations when determining complaints about poor standards of care. The following regulations, relevant to this complaint, require care providers to:

• provide appropriate and person-centred care and treatment based on an assessment of the person’s needs and preferences. (regulation 9)
• assess the risk to people’s health and safety during any care or treatment (regulation 12)
• ensure a person has enough to eat and drink to meet their nutrition and hydration needs and receive the support they need to do so. Nutrition and hydration intake should be monitored and recorded to prevent unnecessary dehydration, weight loss or gain. Action must be taken without delay to address any concerns. Appropriate action must be taken if a person is not eating or drinking enough in line with their assessed needs. (regulation 14 and guidance)
• keep accurate, complete and contemporaneous records of care and treatment (regulation 17)

What happened

Background

11. I have set out a summary of the key events below. It is not meant to show everything that happened.
12. The Council commissioned SH to provide Mr X with residential care. The Council’s care and support plan review completed in February 2019 recorded his nutrition needs, to be met by SH as care provider, as provision of meals and drinks and support for food and fluids intake, offering, prompting and encouraging where necessary.
13. SH’s care plan for Mr X’s nutrition in May 2020 recorded he had a good appetite and enjoyed drinks, and the need to make sure he had sufficient nutrition and hydration.

Events leading up to Mr X’s admission to hospital in August 2020

14. Mrs Y and her family were unable to visit Mr X at SH during this period because of the impact of the Covid pandemic.
15. I have reviewed records provided by SH. These show the following:

• 9 August; Mr X was recorded as having a urinary infection and prescribed antibiotics by the GP.
• 16 August; Mr X refused breakfast and lunch. He said he had something in his throat and appeared confused.
• 17 August; Mr X refused breakfast. SH called the GP. The GP’s note of his visit records poor food uptake in the past few days, throat and chest clear, put Mr X on a soft food diet until he starts to feel better. SH’s daily contact sheets refer to “drink given”, “push fluids”, “drinking fluids well”.
• 18 August; Mr X refused breakfast and was in a very low mood.
• 19 August; Mr X said again he had something in his throat. The GP was called. The GP’s note of his visit records Mr X was refusing food and expressing suicidal thoughts. Psychiatric input would be sought. The contact sheets refer to “fluid done”, “fluids given”, “push fluid and drink”.
• 20 August; Mr X refused breakfast and all meals that day. Paramedics were called because he was agitated, cold and clammy. The paramedics viewed this as more of a mental health issue than physical health. The GP’s advice by telephone was to push fluid, check for urinary infection and wait for psychiatrist’s input and blood test. Mr X’s urinary infection test appeared positive. The contact sheets refer to “encouraged fluids”.
• 21 August; Mr X refused breakfast. His urine sample was sent for testing. The contact sheets refer to “morning fluids given” “seemed better today”, “ate lunch and supper”.
• 22 August; Mr X refused breakfast but drank tea. The contact sheets refer to “morning fluids given”, “ate well lunch and supper”.
• 23 August; Mr X refused breakfast and lunch. The contact sheets refer to “morning fluids given” “ate very little at supper”.
• 24 August; Mr X had a little breakfast, refused lunch and supper. The contact sheets refer to “encouraged to drink fluids”.

16. On 25 August the contact sheets recorded the following about Mr X:

• Refused breakfast. One sip of tea.
• Morning fluids given. We kept going back to check on him and encourage fluids, but he was not swallowing anything.
• He was making groaning noises. Not making any sense.
• No lunch. Appeared agitated. Took a drink but he did not swallow.
• No verbal communication. Just mumbling.
• Fluids pushed. No urine output. No supper.

17. On 26 August, the contact sheets say Mr X seemed very confused, fluids were offered but not swallowed. SH call logs confirm the GP was called at 9.53am. Mr X seemed agitated, was not drinking or swallowing. The GP visited and noted Mr X was acutely unwell, with possible sepsis. An ambulance was called at 14.50pm and Mr X was admitted to hospital.
18. Mr X died in hospital a few days later, on 30 August. Mr X’s hospital notes refer to him being dehydrated, and admitted because of possible urosepsis, delirium, and hypernatremia.
19. A post-mortem found Mr X’s cause of death was pneumonia but no other underlying health conditions that led to his death.

Mrs Y’s complaint

20. Mrs Y and her family met with SH in October 2020 to discuss their concerns about Mr X’s care in the period leading up to his admission to hospital.
21. Their concerns were not resolved. In November 2020 their MP raised the concerns with the Council on their behalf. They asked the Council to investigate whether the care at SH met the required standard.
22. The Council undertook a safeguarding enquiry in response to the family’s concerns. It was unable to visit SH, as it says it would usually do, because of the Covid pandemic. SH, as Nominated Enquirer, was asked to provide information and findings.
23. SH said it found records were in good form but areas for improvement in record keeping included:

• On reflection food and fluid charts should have been put in place
• More alternatives should be offered, eg milkshakes, when meals were being refused.

24. SH also said, in addition to improving its record keeping, when a resident missed a material number of meals it would ensure (if possible) weight would be monitored more frequently and a fluid and food chart put in place when there is a concern. There would also be a review of all other residents.
25. The Council’s Safeguarding Team completed a report which concluded:

• SH had identified improvements required in practices. Records were kept but need to be more detailed and allow for cross referencing and earlier concerns raised. Food and fluid charts are now being kept at an earlier stage when concerns are identified to improve increased monitoring.
• There was no evidence SH was deliberately negligent, but improved record keeping may have identified concerns earlier.
• CQC and the Council’s Quality Improvement team had been updated. CQC would be carrying out an inspection soon.

26. I understand there was a delay by the Council in sharing the outcome of the safeguarding enquiry with the family. It accepted there had been communication failures and it apologised to the family for their distress in the period leading up to Mr X’s death.

Analysis – was there fault by SH causing injustice?

27. It is not our role to decide whether any failings in care or treatment by a care provider are breaches of the fundamental standards. These are matters for the CQC with which we share our decisions.
28. But, having considered the evidence provided, and the 2014 Regulations and guidance referred to in paragraph 9 and 10, my view is the below show failings in the care SH provided for Mr X:

• Mr X began refusing food on 16 August. This was a change to his usual routine, his care plan recorded he had a good appetite and enjoyed drinks. There is no evidence SH updated Mr X’s care plan in response to the GP’s advice on 17 August to put Mr X on a soft diet.
• There is no evidence SH followed the GP’s advice. And it accepted in its response to the safeguarding enquiry more alternatives should be offered, such as milkshakes, when meals were being refused.
• SH said in a response to Mr X’s family, notwithstanding substantive encouragement from its staff to increase his fluid intake, it would not be a surprise to know Mr X was dehydrated on admission to hospital. He had refused fluids on the day of admission.
• But it is clear from the evidence there were concerns about Mr X’s fluid intake days before Mr X’s admission on 26 August. The GP advised SH to push fluids on 20 August, by which time Mr X had been refusing food for a number of days. There is no evidence SH updated Mr X’s care plan to include this advice.
• SH accepts it did not monitor Mr X’s food and fluid intake. Simply referring to ‘’fluids given’’ or ‘’encouraged to drink fluids’’ is not an accurate record of a person’s fluid intake. I consider appropriate action should have been taken to address the significant concerns at this stage about Mr X’s food and fluid intake through food and fluid charts.
• I consider the information recorded in the contact sheets from 23 to 25 August should have alerted SH to the risk of Mr X becoming dehydrated. He had refused almost all the food offered and there was no record of his fluid intake. And by 25 August the information shows he was unable to swallow fluids and his condition was visibility deteriorating. There is no evidence of any assessment of the risk to Mr X’s health or of the need for further medical advice or intervention during this period.

29. I consider the failure to keep accurate records, properly monitor Mr X’s food and fluid intake and assess the risk to Mr X’s health or the need for further medical advice or intervention was fault by SH.
30. I do not consider I can say SH’s care failings led to Mr X’s deterioration and death. But, in my view this fault is likely to have caused Mr X distress. Sadly, we are unable to put this right for him now.
31. I consider the fault also caused Mrs Y and her family distress. It left them with a sense of uncertainty about the standard of care provided to Mr X and the impact of this on him. They spent time and trouble raising their concerns with SH and the Council, at a particularly difficult time for them.

Agreed action

32. 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 have found fault with the actions of Shire House, I made recommendations to the Council.
33. To remedy the injustice caused by the above faults, and within four weeks from the date of our final decision, the Council has agreed to:

• apologise to Mrs Y and her family for the distress caused by Shire House’s failures in its care for Mr X, as detailed in paragraphs 28 and 29 above.
• pay Mrs Y £750 to acknowledge the distress, time and trouble caused to her and her family by the failings in Mr X’s care.
• This figure is a symbolic amount based on the Ombudsman’s published Guidance on Remedies.

34. And within three months from the date of our final decision, the Council will arrange for its Quality Improvement team to:

• review and assess the improvements in practice and record keeping SH put in place in response to the safeguarding enquiry.
• consider with SH whether any further changes should be made in light of the findings in this decision.

35. The Council will provide us with evidence it has done this.

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Final decision

36. I have found fault by the Shire House causing injustice. I have completed my investigation on the basis the Council will carry out the above actions as a suitable way to remedy the injustice.

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Investigator's decision on behalf of the Ombudsman