Summary: Mrs D complains about the standard of care and support her father (Mr H) received while in residential care. Among other things, Mrs D says the Care Provider failed to meet Mr H’s health and care needs and provided him medication he was not prescribed. We found some fault by the Care Provider in relation to its record keeping and care notes. However, there is no evidence to suggest Mr H suffered an injustice as a result of the fault identified. That said, the fault did cause Mrs D an injustice and so we have made a number of recommendations for the Care Provider to remedy this. We did not identify any other fault in this case.

The complaint

1. The complainant, who I refer to as Mrs D, is complaining about the standard of care her father (Mr H) received from Barchester Healthcare Homes Ltd (the Care Provider), before he died. In particular, Mrs D alleged that during Mr H’s brief stay in residential care, the Care Provider was responsible for the following:
1. Administering Mr H medication which he was not prescribed.
2. Failing to understand the circumstances relating to Mr H having a fall.
3. Failing to follow hospital advice to provide Mr H physiotherapy and to keep him mobile following a fall at the residential home.
4. Care and support staff prompted Mr H to engage in recreational activities while his condition appeared poor.
5. Not providing Mr H with enough recreational activities to engage in while in residential care and isolating.
6. Failing to maintain accurate and complete records of care for Mr H.
7. Not meeting Mr H’s nutritional needs which resulted in him being admitted to hospital on a second occasion relating to an acute kidney infection.
8. Not applying Mr H’s needed compression stockings.
2. In summary, Mrs D says the Care Provider’s failures meant Mr H’s quality of life prior to his death was poor. Further, Mrs D says that by not meeting Mr H’s nutritional needs, this contributed to his subsequent illness and death. Mrs D wants the Care Provider to acknowledge its failings and implement service improvements for the benefit of service users in the future.

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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 injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. 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.
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

7. I have read Mrs D’s complaint to the Ombudsman and Care Provider. I have also had regard to the responses of the Care Provider, supporting documents, care records and applicable legislation and guidance. I invited both Mrs D and the Care Provider to comment on a draft of my decision. All comments received have been fully considered before a final decision was made.

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My findings

Background and legislative framework

8. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers which meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards. The fundamental standards include:
1. Care and treatment must be appropriate and reflect service users’ needs and preferences.
2. Service users must be treated with dignity and respect
3. Care and treatment must only be provided with consent
4. Care and treatment must be provided in a safe way
5. Service users must be protected from abuse
6. Service users’ nutritional and hydration needs must be met
7. All premises and equipment used must be clean, suitable and used properly.
8. Complaints must be investigated, and appropriate action taken in response
9. Sufficient numbers of suitably qualified, competent, skilled and experienced staff must be deployed.

Chronology of events

10. Mr H resided with the Care Provider from early February 2021 for 11 days until his admission to hospital. For the first seven days of his stay with the Care Provider, Mr H was required to isolate in his room due to the Covid-19 pandemic.
11. On the fifth day of his stay, Mr H had a fall at the home which required him to be taken to hospital. He returned in the early hours of the sixth day of his stay.
12. On the eleventh day, Mr H was admitted to hospital. Mrs D says Mr H was severely dehydrated at the time and was suffering from an acute kidney infection as a result. After nine days of hospital admission, Mr H died.
13. Mrs D subsequently complained to the Care Provider through its formal complaints policy and procedure. She complained in relation to the issues set out at Paragraph 1 (above). The Care Provider responded to the issues on two separate occasions. However, still dissatisfied, Mrs D brought her complaint to the Ombudsman.

My assessment

Medication administration

14. In summary, Mrs D says Mr H was possibly provided with a medication which should not have been administered to him. She says this is because the medication was listed on the Care Provider’s records on his admission to the home. In response, the Care Provider says it fully acknowledges that Mr H was not take the medication in question. However, because Mr H arrived with the medication in a dossete box, it had to be recorded in accordance with its established procedures. Further, the Care Provider explained to me that Mr H’s medication administration record (MAR) demonstrates he was not provided administered this. I therefore requested the MAR sheets.
15. I have reviewed Mr H’s MAR and the medication in question is not listed for the period the Care Provider cared for him. On that basis, I am satisfied that there is no evidence to suggest Mr H was provided with medication he should not have been. Equally, I am satisfied that the reason the medication in question was listed on Mr H’s admission record was because he arrived with the medication. I have not identified any fault by the Care Provider in this respect.
16. Separately, Mrs D alleges that Mr H was provided paracetamol by care and support staff when this was not prescribed. The Care Provider says that when Mr H was experiencing back pain and discomfort, they provided with him with paracetamol to help comfort him. I am only required to accept a complaint where the alleged fault causes an injustice. This means Mrs D must show a causal link between the Care Provider wrongly giving Mr H paracetamol and him suffering serious loss, harm or distress. In my view, there is no evidence the Care Provider’s actions caused any loss, harm or distress. I do not therefore propose to investigate this part of the complaint.

Fall while in care

17. During the time Mr H resided with the Care Provider, he had an unwitnessed fall and was found in the corridor, outside of his room. The Care Provider’s records show the date and time Mr H was found. These also record that Mr H was transferred to hospital when he was found. Mr H returned to the care home in the early hours of the next morning. Mrs D alleges the Care Provider failed to understand the circumstances which led to the fall and therefore draw lessons from this. However, the Care Provider has already explained that the fall itself was unwitnessed, though recorded in Mr H’s care records once he was found. I fail to see how the Care Provider can give a full and detailed explanation to Mrs D in these circumstances. Mr H was not residing with the Care Provider for 24 hour one to one care and therefore it is not possible for care and support staff to be monitoring him at all times.
18. Further, the Care Provider cannot restrict Mr H’s movements. The evidence I have reviewed suggests Mr H was very frail and quite unwell. My understanding is that Mr H had some cognitive difficulties alongside a diagnosis of vascular dementia, Alzheimer’s disease and prostate cancer. It is clear from the circumstances that Mr H attempted to move either to or from his room, struggled and fell. I fully appreciate Mrs D would have ideally wanted Mr H to have been spotted by care and support staff before he fell. However, it is not realistic nor practical for the Care Provider to prevent all instances of this nature. I have however reviewed the care records maintained by the Care Provider. These demonstrate Mr H was well observed during his time at the care home.
19. In addition, when Mr H returned from hospital to the Care Provider’s home, Mrs D says Mr H was to be provided with physiotherapy and to be kept mobile. However, Mrs D says that Mr H was not offered physiotherapy and was kept largely in his room. On the subject of physiotherapy, this would not be provided, or organised, by the Care Provider. The Care Provider has no care and support staff trained in providing physiotherapy and it is not its role to provide specialist treatment. That is the role of the National Health Service (NHS). I cannot therefore attribute fault to the Care Provider for not providing specialist treatment which does not fall within its remit or owed duties.
20. On the subject of mobility, the evidence I have seen shows Mr H was struggling to keep mobile and was experiencing pain as a result. Further, the Care Provider was informed shortly after Mr H’s fall that the hospital had identified Mr H suffering a fracture. The Care Provider says it was told to expect a call from a physiotherapist, though says no call was ever received. Given Mr H’s mobility problems and that he had suffered a fracture, I cannot attribute fault to the Care Provider for allegedly not keeping him mobile. I believe it would have been reasonable to await contact from the physiotherapist. As a say later in this statement, the Care Provider is not a frontline medical service. Its role is to provide care and support, but in accordance with professional advice. As I understand, the physiotherapist never contacted the Care Provider. It must also be considered that if the Care Provider sought to keep Mr H mobile with a fracture, this could have caused him further pain or harm.

Socialising and recreational activities

21. Part of Mrs D’s complaint is that Mr H had been brought by care and support staff to the visiting area of the home to see his family. It is alleged by Mrs D that Mr H was visibly agitated and distressed and kept falling asleep during this particular visit. She therefore believes that Mr H should never have been bought for visitation by care and support staff. In response, the Care Provider said that its care and support staff had no reason to feel that Mr H was not well enough to attend the visiting area. It also said it recognised the importance of residents interacting with their loved ones. The Care Provider has also commented that while Mr H did appear sleepy, this was not unusual behaviour for him. The Care Provider does not accept that Mr H was distressed or agitated. It is recorded that the nurse did not note any clinical decline in Mr H’s conditions or health.
22. It is clear that Mrs D cared for the wellbeing of Mr H. In my view however, I do not accept the events, as described, are indicative of service failure or fault by the Care Provider. I also do not believe this matter relates to a fall below the CQC’s Fundamental Standards. I have also reviewed Mr H’s care records and I have not identified anything of concern which would lead me to believe that the Care Provider was either neglectful or wrong to have included Mr H within a visit, on the date in question, like any other resident. It may well be the case that Mr H was sleepy and did not engage well with his family during the time of the visit. However, I have not identified any fault by care and support staff exercising their professional judgement that Mr H could reasonably attend the visiting area.
23. Moreover, Mrs D says that Mr H was not provided with enough recreational activities to promote his wellbeing and mental health during his stay with the Care Provider. Importantly, it should be noted that Mr H stayed with the Care Provider for a period of 10 days, during which time he had a brief stay in hospital following a fall. The Care Provider has explained on Mr H’s initial arrival at the home, there was period he was required to isolate due to the Covid-19 pandemic. During this isolation period, Mr H was unable to socialise with other residents, though he did have two one-to-one activities session with a member of the care and support staff. Further, the Care Provider said Mr H engaged with a group activity once his period of isolation ended.
24. There are limits on what I can realistically investigate as I was not present to witness Mr H’s time with the Care Provider. My role is to review the evidence available and draw conclusions about what I consider more likely happened than not. In doing so, I have fully considered the care records made available to me. These suggest to me that Mr H was often tired and sleepy. This is also evidenced by Mrs D's account of her visit to see her Mr H. She said that during her visit, the care and support worker responsible for recreational activities tried to engage with Mr H, but he was sleeping and not responsive. This leads me to believe that frequent engagement with recreational activities was not entirely compatible with Mr H’s condition. I have therefore considered the length of time Mr H stayed with the Care Provider, his health and condition at the time and that he needed a period of isolation when entering the home. My view is that three activities appear proportionate to Mr H’s circumstances. I have not identified any fault by the Care Provider with respect to this part of the complaint.

Care records

25. A primary concern held by Mrs D was that the Care Provider had inaccurately reported Mr H’s health history in his Care Plan. Further, Mrs D explained the numerous erroneous entries in Mr H’s Care Plan appeared to almost refer to a different person entirely. Specifically, the Care Plans stated that Mr H had a history of choking and pneumonia and needs assistance at mealtimes. It also read that he prefers to shower once a week and needs assistance with brushing his hair. Moreover, the notes stated Mr H could eat independently with supervision, was prescribed paracetamol for his back pain and though he could verbalise his needs, he was not very sociable. Mrs D also reports that the ‘activity plan’ and ‘life history’ sections of the Care Plan were incomplete.
26. I would fully expect the Care Provider to accurately record a resident’s needs as this is fundamental to achieving quality outcomes around meeting those needs. The Care Provider has fully acknowledged that there were errors in documenting Mr H’s medical history and needs and it has apologised to Mrs D for this. These errors do constitute fault by the Care Provider and it is easy to imagine how inaccurate reporting of needs could lead to unsatisfactory care outcomes. However, in this case, I have not been provided any evidence or inference by Mrs D to suggest Mr H suffered serious loss, harm or distress as a consequence. In particular, the Care Provider carried a separate risk assessment and concluded Mr H was at a low risk of choking. Further, it says Mr H’s nutritional care was not impacted as a result. However, as I have identified fault, I do welcome Mrs D’s further comments in relation to these issues.
27. More generally, I have completed a review of all of Mr H’s care records made available to me. The evidence shows Mr H’s wellbeing was well observed and that he was regularly checked on. I have not identified any fault in this respect. I have also reviewed all of Mr H’s fluid and food intake records, a detailed assessment of which is shown below.

Nutritional and fluid needs

28. This complaint outcome relates to Mrs D’s most central concern and grievance with respect to the actions of the Care Provider. She reports that when Mr H left the Care Provider’s home and he was admitted to hospital, clinical observations were that he was extremely dehydrated. Mrs D has also expressed deep concerns with respect to Mr H’s nutrition intake while under the Care Provider’s care. In particular, she says his nutrition records demonstrate a low level of food being offered and consumed by Mr H.
29. I will first address the issue of Mr H’s fluid intake. Mrs D says when Mr H left the home, the hospital he was admitted to diagnosed him with an acute kidney infection, resulting from dehydration. Importantly, the Care Provider has made the point that it had no professional involvement with Mr H when he left the home and has not had sight of any clinical observations or assessments made relating to his condition at this point. I have also not been provided evidence to substantiate this allegation. That said, the role of my investigation is limited to establishing whether the Care Provider’s actions were consistent with the CQC’s fundamental standards. My assessment of Mr H’s fluid levels and intake is as follows:
1. Day 1: There is no record available for this date, though this is when Mr H was first admitted to the home.
2. Day 2: Mr H took 1600ml of fluid. This is properly recorded through the fluid intake chart and intake is spread appropriately across the course of the day.
3. Day 3: Mr H took 1600ml of fluid. This is properly recorded through the fluid intake chart and intake is spread appropriately across the course of the day.
4. Day 4: Mr H took 1325ml of fluid. This is properly recorded through the fluid intake chart and intake is spread appropriately across the course of the day.
5. Day 5: Mr H took 1250ml of fluid. This is properly recorded through the fluid intake chart and intake is spread appropriately across the course of the day. Importantly, Mr H was admitted to hospital on this date and so his fluid intake was outside of the control of the Care Provider for majority of the day.
6. Day 6: Mr H took 950ml of fluid. This is properly recorded through the fluid intake chart and intake is spread appropriately across the course of the day. Mr H returned to the care home on this date, though it was in the early hours of the morning which likely would not have impacted on his fluid intake.
7. Day 7: Mr H took 1050ml of fluid. This is properly recorded through the fluid intake chart and intake is spread appropriately across the course of the day.
8. Day 8: Mr H took 650ml of fluid. This is properly recorded through the fluid intake chart. It was recorded that Mr H had not taken adequate fluid intake across the day. It was recommended that care and support staff help and encourage Mr H take more fluids. Further, the record states Mr H now always required assistance to take fluids.
9. Day 9: Mr H took 630ml of fluid. This is properly recorded through the fluid intake chart. It was recorded that Mr H had not taken adequate fluid intake across the day. It was recommended that he be encouraged to do so.
10. Day 10: Mr H took 600ml of fluid. This is properly recorded through the fluid intake chart. It was recorded that Mr H had not taken adequate fluid intake across the day. It was noted that Mr H was, at times, refusing fluids and therefore recommended that he be encouraged to do so.
11. Day 11: Mr H took 470ml of fluid. This is properly recorded through the fluid intake chart. It was recorded that Mr H had not taken adequate fluid intake across the day. It was noted that Mr H was refusing to eat or drink and therefore recommended full assistance to maintain his fluids.
30. I am satisfied the Care Provider has robust measures in place for recording fluid intake. In Mr H’s case, I am also satisfied that care and support staff regularly attended to Mr H in order to maintain his fluid levels. The evidence suggests there was a decline in Mr H’s fluid intake during the final days he stayed with the Care Provider. The written records show this was due to Mr H refusing to take food and drink. It should be noted that the Care Provider must respect Mr H’s choices with respect to taking food and drink, unless a best interests decision has been made for him in accordance with the Mental Capacity Act 2005.
31. In addition, recommendations were made which were aimed at encouraging Mr H to take more fluids and that further assistance be provided to him in this respect. The evidence suggests concerns were growing amongst care and support staff, but Mr H was taken to hospital on Day 10 of his stay which precluded any further action being taken by the Care Provider. I have not found any evidence of fault by the Care Provider and I consider the measures adopted constitute good administrative practice and adhere to the CQC’s fundamental standards.
32. I will now turn to Mr H’s food intake. My assessment of this is as follows:

Day 1: There is no record available for this date, though this is when Mr H was first admitted to the home.

Day 2: Mr H was offered breakfast, half of which was recorded as eaten. The Care Provider’s record for lunch and dinner is blank and no food is recorded as being either offered or eaten.

Day 3: Mr H was offered breakfast, lunch and dinner. The Care Provider’s records show Mr H largely ate all meals, though declined part of his dinner meal.

Day 4: Mr H was offered breakfast, half of which was recorded as eaten and some being declined. The Care Provider’s record for lunch and dinner is blank and no food is recorded as being either offered or eaten.

Day 5: I have not seen any record for this day, though this coincides with the date Mr H had a fall and was taken to hospital for treatment. That said, other records do indicate Mr H ate on this date, but the detail is limited in this respect.

Day 6: Mr H was offered breakfast, lunch and dinner. It was recorded that Mr H ate a quarter of his breakfast meal, though did not eat his lunch or dinner meals.

Day 7: Mr H was offered breakfast, lunch and dinner. It was recorded that Mr H ate half of his breakfast meal. It is not recorded whether Mr H ate his lunch or dinner meals and if so, in what quantity.

Day 8: Mr H was offered breakfast, lunch and dinner. It was recorded that Mr H ate less than a quarter of his breakfast meal. He ate some soup at lunch and declined his dinner meal.

Day 9: The Care Provider’s record is blank and no food is recorded as being either offered or eaten.

Day 10: Mr H was offered breakfast, lunch and dinner. It was recorded that Mr H ate approximately half of each meal, on average.

Day 11: Mr H was offered breakfast, lunch and dinner. He declined each meal.

33. In my view, there is some inconsistency with the quality of the records maintained for Mr H. On some days, meals have not been recorded as offered, or whether they were eaten by Mr H. For two days, no record was made at all. From a record keeping perspective and demonstrating good administrative practice, I have found fault by the Care Provider. A system of robust record keeping is essential to monitoring Mr H's health and care needs and I consider there have been failings in this respect. I must therefore consider whether Mr H suffered serious loss, harm or distress as a result of the fault identified.
34. Whether Mr H has suffered an injustice is dependent on whether he was offered meals by the Care Provider. I do not consider Mr H could have suffered an injustice through poor record keeping alone. I must also consider that Mr H declined the majority of meals he was offered. In terms of what action the Care Provider should have taken in response to this, I must consider that the evidence shows Mr H would likely have refused his meals no matter what health or care environment he was in. The CQC’s guidance states that care providers must follow people's consent wishes if they refuse nutrition and hydration, unless a best interests decision has been made under the Mental Capacity Act 2005.
35. Taking the Care Provider’s records as a whole, I consider it is more likely than not that Mr H was offered his daily meals during his stay. I have not therefore identified fault with respect to the Care Provider meeting Mr H’s nutritional needs. I also believe that Mr H would have eaten what he could and that care and support workers respected Mr H’s wishes when he declined meals.
36. That said, I do find that the food records maintained by the Care Provider have reasonably caused distress and uncertainty for Mr H’s family. It is clear from Mrs D’s correspondence that she was deeply concerned whether Mr H was being offered a sufficient number of meals during his stay. I therefore consider Mrs D has suffered an injustice and that the Care Provider should comply with my recommendations to remedy this. This part of the complaint is partially upheld.

Compression stockings

37. During Mr H’s time with the Care Provider, he was taking blood thinning medication. Mrs D says care and support staff, in this situation, should have provided and applied Mr H compression stockings to help him maintain blood flow and help reduce discomfort and swelling in his legs. Mrs D says the Care Provider failed to do so which caused Mr H to suffer internal bleeding. In response, the Care Provider said it does not normally stock compression stockings and that Mr H did not have a prescription for these. I have reviewed the evidence provided by the Care Provider. Compression stockings usually involves the measurement of a person’s legs because they must provide the right of amount of compression. It is recommended that a person therefore contact their doctor to determine the right stockings which can then be made available through prescription.
38. I fully appreciate Mrs D’s concerns relating to this issue. It may have been the case that compression stockings would have been suitable for Mr H. Importantly, the Care Provider is not a frontline medical service, its role is to provide accommodation, care and support to aid the daily lives of its residents. Had Mr H required compression stockings, it is not the role of the Care Provider to prescribe these and it cannot be expected to stock these when they made to measure. This would be the role of Mr H’s general practitioner who, as I understand, maintained involvement with him during his stay with the Care Provider. I have not identified any fault by the Care Provider with respect to this part of the complaint.

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Agreed actions

39. To remedy the fault and injustice identified in this statement, the Care Provider has agreed to perform the following actions by 1 September 2022:
1. Provide Mrs D a written apology which acknowledges the fault and injustice identified in this statement.
2. Pay Mrs D £150 to serve as an acknowledgement of the distress and uncertainty she suffered as a result of the fault identified.
3. Remind all care and support staff at the care home of the importance of maintaining good records of a service users food intake. This reminder should give an overview of the procedures in place and how to ensure best practice.
40. The Care Provider will provide evidence to the Ombudsman it has satisfied the above actions by the date specified above.

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Final decision

41. The complaint is partially upheld. My investigation found a failure by the Care Provider to maintain accurate and reliable care records which detailed Mr H’s needs and his nutrition intake. Though this did not cause Mr H to suffer an injustice, it did cause Mrs D to suffer distress and uncertainty. I did not identify any other fault by the Care Provider. That said, as I have identified an injustice in this case, I have made a number of recommendations for the Care Provider to remedy this. The Care Provider has accepted these.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman