Summary: Mr C complains the Care Provider did not support his mother properly which led to her premature death. The Care Provider sought medical advice when needed and monitored Ms D’s health adequately. It did not however monitor Ms D’s food and fluid intake or properly consider visits in Ms D’s room. This has caused Mr C uncertainty the Care Provider could have done more to support Ms D. To remedy the complaint the Care Provider should apologise to Mr C and pay him £250. It should also remind staff and review procedures about when it completes nutrition charts.

The complaint

1. The complainant, who I refer to as Mr C, complains about support provided to his late mother, who I call Ms D, at Vicarage Court Care Home.
2. Mr C complains Calsa Care Limited, the “Care Provider” and owner of Vicarage Court Care Home, failed to provide suitable care to Ms D, get urgent medical care, support Ms D with eating, prevented family involvement in Ms D’s care and lost her laundry.
3. Mr C says because of these failures Ms D was in great pain and died prematurely. Mr C does not feel the Care Provider should be paid for inadequate care.

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The Ombudsman’s role and powers

4. 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)
5. This complaint involves events that occurred during the COVID-19 pandemic. The Government introduced a range of new and frequently updated rules and guidance during this time. We can consider whether the care provider followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”.
6. 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.

7. (Local Government Act 1974, section 26A(2), as amended)
8. If we are satisfied with an organisation’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

9. I spoke with Mr C and considered information he provided. I wrote to the Care Provider asking for information and answers to several questions. I considered:-
• all care records;
• the Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. I have used the fundamental standards as a benchmark for considering this complaint.
10. I sent a draft decision and received comments from Mr C and the Care Provider. I considered the comments received and changed my view on some of the complaint. Mr C and the Care Provider had a further opportunity to comment on my second draft decision. I considered any comments received before making a final decision.

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What I found

Background information

11. Ms D was living independently in the community. Ms D entered the care home on 27 July 2021 for two weeks. The Care Provider extended the stay to four weeks.

What should have happened

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 providers must assess risks to people's health and safety during any care and make sure that staff have the qualifications, competence, skills, and experience to keep people safe.
14. Regulation 14 says care providers must meet service user’s nutritional and hydration needs. The associated guidance says care providers,
• “must include people's nutrition and hydration needs when they make an initial assessment of their care, treatment and support needs and in the ongoing review of these. The assessment and review should include risks related to people's nutritional and hydration needs. Providers should have a food and drink strategy that addresses the nutritional needs of people using the service.”
15. Regulation 17 says care providers should “maintain securely” records and should have “an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided”.
16. Government Guidance on care home visiting dated 22 March 2022 says, “visits should take place in a room most practical and comfortable for the resident (for example, residents with dementia may be more comfortable in their own room with familiar belongings)”. By July 2022 the government had relaxed visiting restrictions further allowing care home residents multiple visitors.

What happened

17. On entry to the care home Ms D had constipation. Due to the location of the care home Ms D was not in the “catchment” for her usual GP to visit. The care home however contacted the GP to obtain medication as family bought laxatives were ineffective. The care home received and collected prescription laxatives the next day. Between 28 July and 11 August the care home contacted the GP six times. This was to discuss Ms D's constipation, chronic back pain, and mental health. During this period a staff member found Ms D trying to self-harm using a knife left from lunch.
18. On 11 August Ms D transferred to a local GP who visited Ms D. The care home records family members were also able to speak to the GP.
19. On 13 August the care home contacted the GP concerned that Ms D had again tried to self-harm. Following a referral from the GP a support worker from the mental health team visited Ms D daily. On 17 August the mental health team asked the GP for a medical review of Ms D’s back pain following which the GP prescribed different medication. The social worker asked the care home if Ms D could extend her stay. The care home was only able to extend the stay for two further weeks as it had no vacancies.
20. On 22 August a support worker raised concerns about white spots in Ms D’s mouth and that staff had not helped Ms D with personal care that morning. The support worker asked the care home to contact the GP. The care home completed this action, but Ms D left the care home the next day before the GP could provide any advice. Ms D died two weeks later.
21. During the period of her stay Ms D told staff members she wanted to end her life as she was in so much pain. Staff witnessed Ms D trying to harm herself in several ways. The care notes show Ms D found it increasingly difficult to dress and refused to leave her room as she was in unbearable pain. Both her eating and drinking were also poor.
22. Mr C says the care home refused to let family members visit Ms D in her room. He says had family been able to visit they could have supported Ms D with eating and drinking. Mr C says it was unfair of the care home to insist on Ms D getting up and dressed to have visitors. The Care Provider allowed the family to visit daily. There are three records of when Ms D refused visits from her family.
23. Mr C says the care home lost 10 nightdresses. There is dispute between the parties about the loss of the nightdresses. Both the care home and Mr C say the family agreed to take and complete the daily washing and nightdresses were unlabelled. However Mr C says after the first few days of Ms D’s stay the care home took responsibility for washing the laundry.

Was there fault causing injustice?

24. Ms D entered the care home unwell. The care notes evidence the Care Provider was proactive in responding to Ms D’s developing physical and mental health needs. There was regular contact with the GP and support services from the mental health team were visiting Ms D daily. In addition the Care Provider took suitable steps to lessen any risk to Ms D including hourly checks and removing any items that Ms D might use to harm herself. This is in line with Regulation 12.
25. The location of the care home and the GP’s willingness to complete a visit caused delays and was not the care home’s fault. The Care Provider made positive efforts to change the GP to enable a visit. The nature of Ms D’s back pain is unclear, but I cannot say the Care Provider did not take suitable action to respond to the concerns.
26. The Care Provider did not complete an inventory for Ms D’s items and there is no policy about what happens when the care home does not complete the laundry. This is fault and a potential breach of Regulation 17. However I cannot say the fault caused Ms D injustice. This is because the nightdresses were un-named and it would be difficult for care home staff to keep track of them.
27. The Care Provider’s records show some recording of Ms D’s food and fluid intake. However there was no proper assessment of Ms D’s nutritional needs, how they were changing or how the care home could manage those needs. This is fault and a potential breach of Regulation 14. Mr C has the uncertainty of not knowing whether Ms D’s food and fluid intake would have improved but for the faults identified.
28. Mr C says family would have encouraged Ms D with food if the Care Provider had allowed them to have room visits. Mr C says it was unfair for Ms D to have to dress to go to the visiting area when she was so unwell. There appears to be no record of the family asking the Care Provider if it could accommodate visits in Ms D’s room.
29. The Care Provider has not provided any visiting procedures during the period of Ms D’s stay. It says because of COVID-19, visiting policies were constantly changing and it does not hold the policy for that time period. I have therefore relied on government guidance in place at the time. This says care homes should enable visits where it is most practicable and suitable for the resident. In this case Ms D was in severe pain and found it difficult to leave her bedroom. I therefore consider, notwithstanding a request from the family, the Care Provider should have considered accommodating visits to Ms D’s room.
30. The Care Provider records Ms D refused family visits on three occasions. On balance I think it is more likely than not Ms D refused these visits because she was in too much pain to leave her room.
31. Because of the faults I have identified, Mr C has the uncertainty of not knowing whether room visits were an alternative the Care Provider could have offered for these three visits and other occasions. I cannot however say Ms D would have accepted the visits or that they would have improved her health and well-being.

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Recommended action

32. I have found fault in the actions of the Care Provider which has caused injustice to Ms D and Mr C. Ms D has now died and I cannot remedy her personal injustice. The recommended actions are therefore to acknowledge Mr C’s injustice and improve future practice:-
1. to apologise to Mr C for the faults I have identified in this statement;
2. to pay £250 to Mr C to acknowledge the uncertainty and distress caused by the faults identified;
3. to remind staff, if necessary, provide training and review procedures about the need to complete drink and nutrition charts;
4. review current visiting procedures to ensure they include flexibility on how visits occur.
33. The Care Provider should complete actions (a) and (b) within one month of the final decision and (c) to (d) within three months of the final decision.

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Final decision

34. I have found fault in the actions of the Care Provider which caused Ms D and Mr C injustice. I consider the above actions are suitable to remedy the complaint and have now completed my investigation and closed the complaint.
35. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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Investigator's decision on behalf of the Ombudsman