Summary: Mrs X complained about the standard of care provided to her late father Mr G between May and his death in July 2021 while he stayed at Heathfield House Nursing Homes Ltd (the Care Provider). The Care Provider failed to keep clear and comprehensive records which leaves uncertainty about whether it followed Mr G’s care plan. The Care Provider should apologise to Mrs X and pay her £150 to recognise the distress and uncertainty this caused.

The complaint

1. Mrs X complained on behalf of her father Mr G, about the standard of care provided to him between May 2021 and his death in July 2021 while he stayed at Heathfield House Nursing Homes Ltd. Mrs X complained the Care Provider’s failure to follow his care plan led to Mr G’s death. Mrs X states this caused her significant distress and uncertainty about what happened to her father.

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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. 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.
4. 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)
5. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(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. We normally expect someone to complain to the Care Quality Commission 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)
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

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How I considered this complaint

9. I considered the information provided by Mrs X and I discussed the complaint with her on the telephone.
10. I read the documents provided by the Care Provider in response to my enquiries.
11. Mrs 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

Fundamental Standards of Care

12. 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 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.
14. Regulation 17 states providers must securely maintain accurate, complete and detailed records about each person using their service.

What happened

15. In May 2021 Mr G lived in the Care Provider’s care home. Mr G had lived there for a number of months. Mr G’s care plan set out the diagnosed conditions he had and identified that he was chair and/or bed bound and needed a hoist to be moved. It stated Mr G was doubly incontinent and could not attend to his personal hygiene needs. Mr G had short term memory problems and would not always remember to use the call bell, so he needed regular checks.
16. At the beginning of May 2021, the care records show a carer called the Nurse to see Mr G in the evening as he had vomited. The Nurse recorded his oxygen saturation level was low. The Nurse called 111 and the out of hours doctor arranged for an ambulance to attend. The care records show the paramedics arrived 30 minutes after the Nurse first examined Mr G. Mr G was admitted to hospital.
17. When Mr G returned to the care home the Care Provider received eating and drinking recommendations for Mr G from the Speech and Language Therapy (SALT) service. It said Mr G should be upright and alert for all food and drink. It stated a special precaution was for Mr G to remain seated in an upright position for at least 20 minutes after eating or drinking. It also stated Mr G should have an easy chew diet. It updated Mr G’s care plan in line with the SALT advice. It said Mr G had an impaired swallow and needed supervision and help with all meals and fluid intake. The Care Plan stated all staff should watch Mr G for signs of a chest infection and report them immediately to the Nurse who would assess and escalate to the GP.
18. In the middle of June, the Nurse examined Mr G in the early hours of the morning as he had vomited. The Nurse found he was chesty with low oxygen saturation levels. The Nurse recorded she checked Mr G’s observation levels hourly. Five hours later the record show Mr G’s oxygen saturation level had decreased further, the Nurse recorded he would be reassessed and the GP called if deemed necessary. A further hour and a half later the Care Provider reassessed Mr G, by which time his oxygen saturation level had improved slightly. The Care Provider then called the out-of-hours doctor who called an ambulance. Mr G was admitted to hospital from the care home.
19. The Paramedic who saw Mr G told the Nurse they were concerned she had waited seven hours while Mr G deteriorated before calling for assistance. They told the Nurse they intended to make a safeguarding referral for neglect. The Paramedic sent a safeguarding concern to the Council. They stated they were concerned about neglect as the Care Provider had not treated Mr G for an episode of aspiration and had not maintained Mr G’s personal hygiene.
20. A week later Mr G returned to the care home. The discharge letter recommended a diet of easy chew foods and thickened fluids. It stated Mr G should not use beaker lids or straws and should be sitting upright in midline.
21. At the end of June the Care Provider completed a risk assessment for the risk of Mr G choking and dying. It stated staff should follow the SALT recommendations. It said Mr G should be upright and staff should encourage him to eat and drink slowly. Staff should supervise Mr G during all mealtimes.
22. The Care Provider updated Mr G’s care plan. Written instructions about Mr G’s posture were put on the board in the kitchen and it had made staff aware of the update.
23. In July the records show the Care Provider gave Mr G breakfast. The records do not specify what time Mr G received his breakfast. At 10am the positioning chart shows he was sitting upright and eating. At 11:20am a cleaner noticed Mr G looked unwell and called the Nurse. The Nurse examined Mr G and found that he was not breathing. Mr G had died.
24. In August Mrs X contacted the Care Provider. She asked for further information about the circumstances of her father’s death and the feeding arrangements that were in place. Mrs X also asked for copies of Mr G’s records from May 2021.
25. In September the Care Provider responded. It stated the carer supervised Mr G to eat his breakfast and then left him at 10.30am after she had ensured he had swallowed what was in his mouth. The Care Provider did not provide any further information to Mrs X.
26. Mrs X contacted the Care Provider again in October 2021 and asked for more clarity about what had happened on the day Mr G died. Mrs X said the Care Provider did not respond to her.
27. The Coroner held an inquest in October 2021. It found that Mr G’s death was accidental and that he had choked on food. A carer provided a statement for that inquest and stated she waited until Mr G had finished his mouthful of food and then left the room with his tray.
28. Dissatisfied with the Care Provider’s response Mrs X complained to us. I discussed the complaint with Mrs X. She stated she was dissatisfied with the level of care provided by the Care Provider but had not raised this with the Provider. She stated she had been made aware of the safeguarding referral by the paramedic after Mr G had died.
29. As part of this investigation, I have reviewed the daily records of the care and support Mr G received. Each day there were two entries that provided a brief overview of the day and the night. Some records stated Mr G ate and drank upright and some do not specify. The record does not show who supervised Mr G while he was eating or for how long they stayed with him once he had finished. I have not seen any record of what cups the Care Provider used to provide Mr G’s drinks.
30. In response to my enquiries the Care Provider stated the Council had contacted it about a safeguarding concern for Mr G in June. It did not provide any further details.

My findings

31. Mrs X’s substantive complaint to us was about the level of care Mr G received on the day he died. Although Mrs X said she was unhappy with other aspect of care Mr G had received, she had not complained to the Care provider about those matters. Therefore, I have not completed an audit style investigation into Mr G’s care but have investigated the care Mr G received on the day he died.
32. In June the Care Provider had updated Mr G’s care plan in line with the discharge advice from the hospital and SALT. It stated the Care Provider should monitor Mr G for signs of a chest infection and escalate any concerns to the GP. When the Nurse examined Mr G after he had vomited, she found that he had signs of a chest infection. When Mr G’s observations were repeated five hours later, he had deteriorated further. In response to the draft decision the Care Provider said it was a judgement call by the Nurse whether to escalate concerns. There is no record of the Care Provider’s consideration of escalating its concerns for Mr G’s health at either point. The lack of clear records was fault and caused uncertainty about whether the Care Provider followed Mr G’s care plan. However, I cannot say what injustice this caused as it is not known how the outcome would have been different had the delay not occurred.
33. In July Mr G’s care plan stated the Care Provider needed to check Mr G regularly. Mr G’s risk assessment said he was at risk from choking. His care plan specified he must be upright and supervised when eating and drinking and must remain upright for 20 minutes afterwards. On the day he died Mr G was upright and eating at 10am. There are no records to show how the Care Provider supervised Mr G. There are no records that show how it ensured Mr G remained sitting upright for 20 minutes after he had finished eating. The carer’s statement says she left the room when Mr G finished his mouthful and he was later found unresponsive. The lack of clear records leaves uncertainty around whether the Care Provider properly followed Mr G’s care plan and supervised him or ensured he remained upright for 20 minutes after eating. That was fault and caused uncertainty to Mrs X as to whether Mr G was provided with the care specified in his care plan.
34. The Care Provider’s record keeping was inconsistent. The food and fluid intake charts do not provide enough information about when the Care Provider gave Mr G food. It does not specify what support or supervision it gave Mr G to eat or what cups it used for his drinks. These were important parts of Mr G’s care plan and risk assessment and so it should have kept comprehensive and accurate records. The daily record had inadequate information with only two entries per 24 hour period covering all care and support. The lack of clear and detailed record keeping is not in line with fundamental standard regulation 17 and was fault. It leaves Mrs X with uncertainty about whether the Care Provider consistently followed Mr G’s care plan.
35. The paramedic made a safeguarding referral to the Council. I have not investigated the circumstances of that referral because they made it to the Council. It is open to Mrs X to contact the Council in relation to what steps it took following the referral.

Injustice arising from the fault

36. Mr G 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 Mr G.
37. However, Mrs X has been caused distress and uncertainty in relation to whether Mr G experienced avoidable harm in relation to the failure to follow his care plan and failure to keep accurate and comprehensive records. The Care Provider should make a symbolic payment to acknowledge this injustice.

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Recommended action

38. Within one month of this decision the Care Provider should:
• apologise to Mrs X and pay her £150 to recognise the distress and uncertainty caused to her by the faults outlined above; and
• remind staff to ensure they accurately, consistently and comprehensively record activities of daily living to reflect how it is meeting resident’s needs as set out in their care plans.
39. The Care Provider should provide us with evidence it has done so.

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Final decision

40. I have completed my investigation. I found fault causing injustice and I have made recommendations to remedy that injustice.

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Investigator's decision on behalf of the Ombudsman