Summary: Mrs F complained the Care Provider failed to provide acceptable care to her father during his stay at its care home. She also says it failed to properly organise family contact and visits and it discharged him from the care home when he had COVID-19. We find the Care Provider failed to maintain complete records. The Care Provider has agreed to our recommendations to address the injustice caused.

The complaint

1. Mrs F complained the Care Provider failed to provide acceptable care to her father, Mr G, during his stay at the care home. She also says it failed to properly organise family contact and visits and it discharged him from the care home when he had COVID-19.
2. Mrs F says Mr G felt neglected, uncared for and isolated. It has also caused the whole family distress.

Back to top

The Ombudsman’s role and powers

3. 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”.
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. We may investigate complaints made on behalf of someone else if they have given their consent. (Local Government Act 1974, section 26A(1), as amended)
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)
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

Back to top

How I considered this complaint

8. I considered information from Mrs F. I made written enquiries of the Care Provider and considered information it sent in response.
9. Mrs F and the Care Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

Back to top

What I found

Care home regulation and guidance

10. 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.
11. 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.
12. Regulation 14 says care providers must meet service user’s nutritional and hydration needs.
13. 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”.

What happened

14. Mr G was admitted into the Care Provider’s care home, Cubbington Mill, in December 2021 for respite care.
15. Mr G went into hospital a few days later and a doctor diagnosed him with pneumonia.
16. Mr G returned to the care home after five days.
17. Mr G’s family were unhappy about the standard of care he received and decided to bring him home.
18. On the day of discharge, Mr G’s family noticed he was unwell. He became unresponsive and experienced breathing difficulties. They called an ambulance, and a paramedic checked him and carried out a COVID-19 test. Mr G tested positive for COVID-19.
19. Mrs F complained to the Care Provider about the standard of care Mr G received. She said her husband had to intervene for it to act regarding Mr G’s pneumonia. She said it was difficult to speak to Mr G, the family’s calls went unanswered, and her mother visited the care home but could not enter. She said Mr G was left alone naked from the waist down for an extended period and staff left cold food in Mr G’s room and failed to offer an alternative. Finally, she said Mr G did not receive paracetamol four times a day and it failed to check whether he had COVID-19 before it discharged him from the care home.
20. The Care Provider responded to Mrs F’s complaint. It said:

• Staff were regularly observing Mr G before they sought external professional support when a clinical decline was obvious.
• It could not identify any missed calls for Mr G.
• Staff encouraged Mr G to eat and drink and offered him alternatives. There was an isolated incident when staff left cold food in Mr G’s room, but alternatives had been offered.
• It was sorry that her mother visited Mr G and observed him undressed from the waist down. Care staff supporting Mr G said he declined their support to get fully dressed.
• A doctor did not prescribe Mr G paracetamol on his admission to the care home.
• It was sorry there was a breakdown in communication resulting in her mother arriving at the care home but being unable to enter.
• Mr G had a lateral flow test for COVID-19 five days before he was discharged from the care home. He received a negative test result the day before he was discharged.

21. Mrs F remained dissatisfied and referred her complaint to the Ombudsman.

Back to top

Analysis

22. Mrs F says if her husband had not intervened, the Care Provider would not have contacted the emergency services about Mr G’s declining health. The Care Provider has a different view and says it was aware Mr G was experiencing breathing issues and it had already called the nurse to observe him.
23. The care records show the Care Provider was aware Mr G was breathless. It took his temperature, observed his heart rate, and repositioned him. When it observed him again in the afternoon, it became concerned that his health was deteriorating and therefore called 999. There is no evidence to support Mrs F’s statement it only intervened because of her husband.
24. I have not seen any evidence of calls that took place between Mr G and his family. Therefore, I cannot make a decision either way whether calls went unanswered.
25. The Care Provider accepts there was a breakdown in communication and a wrong interpretation by staff. This meant Mrs F’s mother went to visit Mr G at the care home but was declined entry when she arrived. It has apologised for the upset caused. This is a satisfactory remedy.
26. Mrs F says Mr G should have received paracetamol four times a day, but this did not happen. I have checked the pre-admission information and can find no evidence that the medical centre prescribed Mr G paracetamol four times a day. The notes state Mr G would verbalise when he was in pain. Therefore, I do not uphold this part of Mrs F’s complaint.
27. The Care Provider apologised for an occasion when Mr G was left naked from the waist down. It says the manager of the care home discussed the issue with Mr G and with care staff. It also says Mr G declined to get dressed.
28. Mrs F says staff left Mr G undressed for an extended period. I have not been provided with any documentary evidence of this incident and therefore it is difficult to reach a finding on what precisely happened. There is some conflicting information between Mrs F and the Care Provider. However, the Care Provider has accepted it caused the family distress and has apologised for it.
29. Mrs F says the Care Provider failed to ensure Mr G had anything to eat or drink on several occasions. The Care Provider says Mr G’s dietary intake fluctuated. I have reviewed the food charts and find there are some occasions when it is not recorded whether staff offered Mr G an evening meal. There is also missing information on what Mr G had to eat on the day he went into hospital. He did not go into hospital until the late afternoon, and so staff should have been recording what he ate until then. There are also some large gaps in the fluid charts and so it is not clear if staff offered Mr G fluid and he declined it, or it was not offered at all.
30. Regulation 17 of the CQC guidance is clear that all care providers should maintain accurate, complete, and contemporaneous records in respect of each service user. Accurate record keeping is vital for the safe delivery of care. There is no evidence the Care Provider’s failure in record keeping had a detrimental impact on Mr G’s health. However, it has caused some worry and uncertainty for Mr G’s family about whether his nutritional and hydrational needs were met during his stay at the care home.
31. The Care Provider acknowledges it did not test Mr G for COVID-19 on the day of discharge. However, it says it was for the family or a new care provider to arrange a test. It says Mr G’s family did not ask for him to be tested before he was discharged.
32. The Care Provider does not have a specific COVID-19 discharge policy. Therefore, I have checked the government guidance that was applicable at the time. There is nothing in the government guidance which states care homes were required to test service users before discharging them home. Therefore, while I appreciate the upset caused to Mr G and his family, I do not uphold this part of the complaint.

Back to top

Agreed action

33. To remedy the injustice caused, by 21 December 2022 the Care Provider has agreed to:

• Apologise to Mrs F.
• Pay Mrs F £150 for her worry and uncertainty.

34. By 20 January 2023 the Care Provider will:

• Remind all care and support staff at the care home the importance of maintaining complete and accurate records of a service user’s food and fluid intake. This reminder should give an overview of the procedures in place and how to ensure best practice.

Back to top

Final decision

35. I have completed my investigation and find the Care Provider’s actions caused an injustice. The Care Provider has agreed to my recommendations and so I have completed my investigation.

Back to top

Investigator's decision on behalf of the Ombudsman