Summary: Ms C complains the failure of the Care Provider to properly support her father led to his premature death. The Care Provider has already accepted it failed to provide Cardiopulmonary Resuscitation (CPR). It is also at fault for inadequate records. This has caused uncertainty about what care Mr D received and whether the Care Provider properly cared for him. To remedy the complaint the Care Provider has agreed to apologise to Ms C and pay her £650 in acknowledgment it did not follow CPR policies properly and the uncertainty the lack of care records has caused. It will also provide training to care staff about the importance of proper recording, review the process it uses for recording interventions and take the steps it has already identified in training and supporting staff with CPR.

The complaint

1. The complainant, who I call Ms C, complains on behalf of her late father who I call, Mr D. Ms C complains Aldergrove Manor Care Home, the “Care Provider” failed to provide appropriate care to Mr D which led to a decline in his health and his premature death. Aldergrove Manor Care Home also failed to support Mr D when he was approaching death and when he died.
2. Because of these failures Ms C says she has anger and frustration that, but for the failures of the care home, her father would have lived longer. She has had the time and trouble in pursuing her complaints with various bodies and the upset of knowing the care home did not act as it should have when her father stopped breathing.

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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 an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
4. 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.
5. This complaint involves events that occurred during the COVID-19 pandemic. The Government introduced new and often 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. 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

7. I read the paperwork Ms C provided and spoke with her about her complaint. I made enquiries of the Care Provider asking questions and for written information. I considered:-
• Mr D’s care records, incident reports, risk assessments and care home policies;
• 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. It also has power to enforce against breaches of fundamental care standards and prosecute offences. I have used the fundamental standards as a benchmark for considering this complaint.
8. Ms C 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

Background information

9. Mr D was living in the community. He had vascular dementia and entered the care home for a short stay on 26 February 2021. He stayed there until his death on 3 April 2021.

What should have happened

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.
11. Regulation 9 “Person Centred Care” says care providers should enable and support relevant people to make or participate in making, decisions relating to the service user's care or treatment to the maximum extent possible…”.
12. Regulation 10 says care providers must make sure they provide care and treatment in a way that always ensures people's dignity and treats them with respect.
13. Regulation 12 aims to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Care providers must assess the risks to people's health and safety during any care or treatment and act to mitigate risks.
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 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.”

What happened

16. Ms C says during Mr D’s stay at the care home he lost weight, was not eating or drinking and his health worsened. Due to COVID-19 family visits were limited but on a visit the day before Mr D died Ms C was shocked to see his general condition.
17. On 3 April 2021 Mr D was sleepy and care staff were therefore making regular checks. At 4pm care staff recorded Mr D was fine and breathing, 14 minutes later a senior carer checked Mr D and he was unresponsive. Over the next 28 minutes various carers were involved but no CPR performed. At this point a senior carer intervened. They had not acted earlier as they say they were dispensing medication to other residents. Mr D did not have a, Do Not Resuscitate, (DNR) in place. Ambulance services pronounced Mr D dead at 5.15pm.
18. The care home completed a serious incident review and recommended and completed a range of actions including :-
• staff to follow emergency protocols immediately without hesitation, to familiarise themselves with protocols and raise any concerns or queries with the care home;
• communication about emergencies to be clearer. CPR protocol to be understood and followed;
• staff to receive on the spot training about the understanding of, Do Not Attempt Cardiopulmonary Resuscitation, (DNACPRS) and unexpected death protocols with and without DNACPRS. Sign sheet for all staff to evidence this;
• staff meetings to be held to ensure every department understands their own responsibilities;
• E-Learning for basic life support and first aid refresher for staff;
• all DNACPRs reviewed by GP surgery and any resident without one is clearly highlighted;
• action taken against staff members;
• all staff to understand the protocols surrounding expected deaths that have a DNACPR and those who do not;
• staff to challenge and use initiative in an emergency situation where lifesaving practices are needed.
19. The care records do not provide detail about the support Mr D received. There are notes of staff advising family of a urine infection, two falls one of which resulted in a fractured wrist, and a deterioration in Mr D’s mental health.
20. There is a note of a phone call on 1 April a few days before Mr D died about Ms C’s concerns. The home manager reports Mr D as having a urine infection and becoming disinhibited within the home. The manager records Mr D as “frail and ultimately deteriorating in condition”.
21. Ms C was unable to visit Mr D because of the pandemic until the day before his death. Ms C says trying to get through to the care home was difficult and time consuming. Ms C says the attitude of some care staff over the phone was upsetting and care staff appeared to show little compassion.
22. The Care Provider’s response to Ms C’s complaint apologised for the difficulties in getting through to the care home, saying it would look at ways to resolve the problem. It apologised for the way some staff members talked to Ms C and said it would investigate the incidents and address the issues with staff members.
23. The Care Provider explained why Ms C’s brother could not visit in her place at an earlier prearranged visit due to the essential caregiver rule as set by the government guidelines in place at the time.

Is there fault causing injustice?

24. I do not intend to reinvestigate matters set out in paragraph 21 as the Care Provider has accepted fault. Similarly the failure to have an “End of Life Plan” for Mr D and to follow CPR procedures is fault and a potential breach of Regulations 9, 12 and 17. The Care Provider has accepted this was a serious incident. It has taken action to avoid a repeat of what happened to Mr D and apologised to Ms C. I have however made further recommendations below to address the injustice caused to Ms C from these faults and to improve future practice.
25. The care records for Mr D are inadequate. There is no nutrition support plan which identifies what Mr D needed daily for his nourishment and no evaluation about whether he was eating or drinking enough. This is a potential breach of Regulations 12 and 14.
26. The daily care records consist of a tick box exercise with no commentary. It is therefore difficult to find out what individualised care Mr D received or any evaluation of Mr D’s daily needs. This is fault and a potential breach of Regulations 12 and 17.
27. There are communication notes about some of Mr D’s difficulties. However there are no updated risk assessments or care notes which say what care staff did to contact relevant health professionals and how the Care Provider was supporting Mr D with his increasing needs. This is fault a potential breach of Regulations 9, 10, 12, and 17.
28. A recently completed CQC inspection report highlights some inadequacies in the support provided by the Care Provider. In particular the failure to update risk assessments and care plans, lack of fluid monitoring charts, and the availability of staff. When Ms C saw her father he had lost weight and looked in a poor state of health. Considering all the information available above I consider on balance it is more likely than not Mr D did not receive the care he should have.
29. In response to a draft of this decision Ms C says the Care Provider’s decision not to allow her brother to visit was unnecessary and vindictive and that had her brother been allowed to visit he would have removed Mr D. The Care Provider is at fault for failing to record the reason why it would not allow a change in essential caregiver at that time. I am however unable to say another family member would have been able to visit at the time or indeed that the family would have moved Mr D as his health had declined.
30. While we cannot remedy Mr D’s injustice Ms C has had anger, anguish, and frustration in knowing the actions taken by care staff leading up to and at the time of her father’s death were inadequate. She has had time and trouble in pursuing the Care Provider for service improvements. While I cannot say Mr D would not have died when he did, Ms C has the uncertainty that but for the faults identified Mr D may not have died when he did.

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Agreed action

31. The role of the Ombudsman is to remedy injustice where we have found fault or service failure. We cannot remedy Mr D’s injustice as he has now died. Ms C says she wants the care home shut down. We do not have the power to close care homes. This is a matter for CQC. The agreed action is intended to improve future practice and to remedy Ms C’s personal injustice. The payments agreed are an acknowledgement of the failures identified not a reflection of the full impact on Ms C. The Care Provider has agreed to:
1. apologise to Ms C for the faults I have identified, including the failure to:
1. complete CPR for Mr D;
2. properly record interventions for Mr D;
3. provide adequate care to Mr D;
4. properly communicate with Ms C.
2. pay Ms C £650 for her uncertainty, anger and frustration caused by the faults identified;
3. evidence the steps it said it would take at paragraph 18:
1. staff to follow emergency protocols immediately without hesitation, to familiarise themselves with protocols and raise any concerns or queries with the care home;
2. communication about emergencies to be clearer. CPR protocol to be understood and followed;
3. staff to receive on the spot training about the understanding of, Do Not Attempt Cardiopulmonary Resuscitation, (DNACPRS) and unexpected death protocols with and without DNACPRS. Sign sheet for all staff to evidence this;
4. staff meetings to be held to ensure every department understands their own responsibilities;
5. E-Learning for basic life support and first aid refresher for staff;
6. all DNACPRs reviewed by GP surgery and any resident without one is clearly highlighted;
7. action taken against staff members;
8. all staff to understand the protocols surrounding expected deaths that have a DNACPR and those who do not;
9. staff to challenge and use initiative in an emergency situation where lifesaving practices are needed.
4. review the process it uses to record daily interventions so they include commentary and evaluation about the actions care staff have taken;
5. reviews how care staff monitor food and drink ensuring each person has a nutrition support plan which staff apply daily;
6. once the Care Provider has completed the reviews provide training to staff about recording and the new processes the Care Provider has implemented.
32. The Care Provider should complete (a) within one month of the final decision and (b) to (f) within three months of a final decision.

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Final decision

33. I have found the Care Provider’s actions have caused injustice to Mr D and Ms C. I consider the agreed actions above are suitable to remedy the complaint. I have now completed my investigation and closed the complaint on the basis of the agreed actions.
34. 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