Summary: Mrs X complains about the care her late grandmother, Mrs Y, received at St Catherine’s Care Home, which is run by Community Integrated Care (CIC). CIC accepts the Care Home did not keep proper records of the care provided for Mrs Y and did not assess all her needs properly. This means it cannot evidence all the care provided for Mrs Y and is unlikely to have met all her needs properly. This has caused avoidable distress to her family. CIC needs to apologise, make a symbolic payment to her family and take action to prevent similar failings.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains about the care her late grandmother, Mrs Y, received at St Catherine’s Care Home (the Care Home), which is run by Community Integrated Care (CIC).

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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)

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How I considered this complaint

3. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the comments and documents the care provider has provided in response to my enquiries;
• considered the Ombudsman’s guidance on remedies; and
• shared a draft of this statement with Mrs X and the care provider, and taken account of the comments received.

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What I found

Key facts

4. Mrs Y moved to the Care Home in March 2020. According to its records:
• Mrs Y could not walk because of a lack of feeling in her legs;
• she elected to remain in bed, rather than use a body sling and hoist to get out of bed;
• she lacked motivation and, for instance, would let staff wash her upper body although she could have done this herself;
• if she slipped down in bed staff used a slide sheet to change her position as she could not do this herself;
• she enjoyed doing puzzles and had a mobile phone and tablet, which enabled her to keep in contact with her family;
• it assessed Mrs Y’s skin integrity as “at risk” until August 2020 when it assessed it as “at very high risk”; and
• she could eat and drink herself but in the time leading up to her death her appetite declined and she regularly refused meals.
5. Mrs Y died in the early hours of 19 March 2021.
6. Mrs X complained about the care her grandmother received in the Care Home.
7. When responding to Mrs X’s complaint in June 2021, CIC said in summary:
• it accepted it had not assessed the risks to Mrs Y’s skin integrity properly and failed to identify her as “high risk”;
• Mrs Y had an airflow mattress when she first arrived but did not like it, so staff replaced it with a high-grade foam mattress, with her consent, which was suitable for someone, such as Mrs Y, who could move themselves in bed;
• staff had not completed weekly body maps, as required, but had done this monthly (apart from August and September 2020);
• it had position turning charts, although some charts were missing (noting that during an outbreak of COVID-19 between October and December 2020 record keeping was not always consistent);
• staff reported Mrs Y taking her feet off the pillows used to elevate them;
• it had not assessed the risk to Mrs Y from malnutrition in May or June 2020, or February 2021, which was not acceptable;
• Mrs Y had often been reluctant to eat, despite encouragement from staff;
• it should have discussed this, and the general decline in Mrs Y’s health, with a GP, which could have led the GP to supporting the Care Home with an end‑of‑life plan for her;
• it accepted “with hindsight” that it could have done much more to support Mrs Y with her mental health, including her care plan which did not do enough to support her settle into the Care Home;
• it apologised if any of the language in Mrs Y’s care plans came across as negative, as that would not have been anyone’s intent;
• it apologised for not assessing Mrs Y for depression each month;
• it accepted the Care Home had not dealt properly with Mrs Y’s medication when she ran out of medication shortly after arriving; and
• it apologised for not producing an end-of-life care plan when Mrs Y arrived at the Care Home.
8. Mrs X sent a detailed response to CIC which, in summary, said:
• the Care Home had not recorded a conversation with Mrs Y about the airflow mattress and she questioned whether the conversation had happened;
• all Mrs Y’s care records said she could not move and needed two members of staff and a slide sheet to reposition her;
• the records said Mrs Y had bleeding under the skin on her heels but also recorded “no concerns”;
• the lack of body mapping records for August and September was significant as Mrs Y had received antibiotics (prescribed on 20 July) for an infected pressure ulcer;
• a significant number of positioning charts were missing;
• she disputed the suggestion Mrs Y could move her feet from the pillows;
• the two occasions staff found Mrs Y without her heels elevated (6 and 7 March) were when she was extremely poorly, so she could not have moved herself;
• the Care Home never documented a reluctance to eat;
• it had failed to support Mrs Y with her mental health;
• she had only managed one video call with Mrs Y because of the resistance of staff at the Care Home;
• the fact all care homes experienced medication errors did not excuse the fact Mrs Y was without medication for five days;
• Mrs Y had never been fitted with a catheter, despite a GP prescribing one;
• staff should not have waited two hours before taking another oxygen reading on 19 March, when Mrs Y died;
• staff waited too long to call 999 on the day Mrs Y died (two hours after recording an oxygen level of 90%);
• questioned whether staff had given medical professionals the correct information on the night Mrs Y died;
• if staff had followed the care plan for skin integrity, Mrs Y may have received more timely treatment and experienced less discomfort;
• it should not have been possible for staff to find Mrs Y without her heels elevated two days in a row (6 and 7 July);
9. CIC sent a further letter to Mrs X in July, saying:
• it accepted the Care Home could have better recorded some of the information;
• a Tissue Viability Nurse had recommended a foam mattress but staff at the Care Home decided to see if Mrs Y would be more comfortable on an airflow mattress, but she did not like the noise it made and was not comfortable. The foam mattress could be used for some whose skin integrity was at “very high risk”;
• the Care Home should have recorded the discussion with Mrs Y about the pros and cons of an airflow mattress;
• it was right for the Care Home to re-evaluate the use of an airflow mattress in March 2021 and advise Mrs Y to try one again, as the risk of pressure ulcers to her heals had increased as she could not keep her legs elevated on pillows placed lengthways under her calves;
• it should have documented the fact Mrs Y could move her legs slightly, resulting in them slipping off the pillows, and the reason for recommending an airflow mattress again;
• the Care Home should not have recorded “no concerns” when there was evidence of non-blanching (bleeding under the skin) on her heels. But the Care Home was addressing the problem by elevating Mrs Y’s legs on pillows;
• the Care Home had referred Mrs Y to a Tissue Viability Nurse many times during her stay;
• an infected wound to Mrs Y’s heels had been treated with antibiotics in July 2020;
• although positioning records were missing, it believed this was because they had been mislaid, rather than that they had not been produced (it had made changes to minimise the risk of this happening);
• the Care Home apologised if staff had appeared difficult when asked to arrange video calls with Mrs Y;
• it apologised for the offence caused by saying all care homes experienced medication errors. It had not intended to minimise the significance of the incident;
• the wrong sized catheter had been issued. When this was pointed out, a GP decided not to prescribe another catheter as Mrs Y’s blisters were in a better condition and the risk of infection from a catheter outweighed the potential benefits;
• on the day Mrs Y died the nurse had checked Mrs Y regularly after her oxygen level fell to 90%, but failed to record her checks and could not recall the times. After noticing a difference in Mrs Y’s breathing, the nurse called 999 and received advice to place Mrs Y on the floor. After she vomited, staff moved her onto her side. When the paramedics arrived Mrs Y had died; and
• the Care Home had referred Mrs Y to a GP for a mini mental state examination (to check for capacity issues), which the GP did remotely with support from staff at the Care Home. The GP found no evidence of significant impairment which would have compromised Mrs Y’s capacity to make decisions.

Did the care provider’s actions cause injustice?

10. 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. Regulation 17 requires care providers to maintain an accurate, complete and contemporaneous record of the care provided for each service user.
11. CIC responded fully and openly to Mrs X’s complaints. It accepts the Care Home did not keep proper records of the care provided for Mrs Y. This is a potential breach of Regulation 17. Our own guidance (see paragraph 3 above) emphasises the importance of good record keeping during a time of crisis. The lack of proper records means CIC cannot evidence having met Mrs Y’s needs properly. That is an injustice.
12. CIC also accepts the Care Home did not assess all Mrs Y’s needs properly and that its care plans were not as comprehensive as they should have been. This included skin integrity, mental health, nutrition , as well as end of life care. This means the Care Home is unlikely to have met all Mrs Y’s needs. That is a further injustice.
13. The evidence indicates Mrs Y could not move her legs. It therefore seems unlikely she could have moved them off the pillows used to elevate them to protect her heals. However, that does not rule out the possibility of her legs slipping off the pillows, as a result of other movements she made. That is reflected in the fact staff needed to use a slide sheet if she involuntarily slipped to a different position in bed.
14. It is no longer possible to remedy the injustice to Mrs Y as she has died. However, the failure to meet all Mrs Y’s needs has caused avoidable distress to her family, which is also an injustice.

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Recommended action

15. I recommended CIC:
• within four weeks sends Mrs X a further apology and pays £500 to remedy the injustice caused to Mrs Y’s family by the Care Home’s failings; and
• within eight weeks set out the action the Care Home is taking to address the failings identified in this statement.

CIC has agreed to do this.

16. Under the terms of our Memorandum of Understanding and information sharing protocol with CQC, I will send it a copy of this statement.

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Final decision

17. I have completed my investigation on the basis CIC’s faults have caused injustice which requires a remedy.

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Investigator's decision on behalf of the Ombudsman