Lancashire County Council (21 018 340)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 02 Dec 2022

The Ombudsman's final decision:

Summary: We uphold Mr X’s complaint about the care and treatment provided to his mother, Mrs Z. We found fault with the way the Trust and the Council handled Mrs Z’s discharge from hospital and how staff communicated with her during her physiotherapy assessments. We also found fault with the Council’s record keeping, communication and Mrs Z’s continence care. As a result, Mrs Z experienced unnecessary discomfort which impacted on her dignity and Mr X was caused stress and worry. The Trust and Council will apologise to Mr X and Mrs Z and pay a total of £450. They will also take action to prevent similar problems occurring in the future.

The complaint

  1. Mr X complains about the way his mother’s discharge from hospital to a care home was handled by Lancashire County Council (the Council) and East Lancashire Hospitals NHS Trust (the Trust) in February 2020. Mr X complains that
    • he was not adequately involved in choosing the discharge location for his mother, Mrs Z,
    • Mrs Z’s wheelchair was not transferred with her when she was discharged,
    • there was a lack of support to return Mrs Z home,
    • her assessments and therapy sessions were delayed; and
    • Mrs Z was not provided with an appropriate interpreter during her physiotherapy assessments
  2. He is also unhappy with the care provided to Mrs Z by Victoria Care Home (the Care Home) on behalf of the Council as part of her short-term Discharge to Assess placement. Mr X complains that the Care Home failed to
    • properly supervise Mrs Z leading to falls,
    • notify the family or seek appropriate medical advice following Mrs Z’s fall,
    • provide adequate personal care to Mrs Z,
    • properly manage Mrs Z’s swollen legs; and
    • make the correct adjustments to her food, fluid and medication.
  3. Mr X says the Care Home failed to effectively communicate with Mrs Z’s family and the manager falsely claimed the family had been consulted.
  4. He is also unhappy with the Council’s handling of his safeguarding concerns.
  5. As a result, Mr X says that his mother has been left distressed, afraid of being alone and unable to sleep properly. Mr X has also found the situation stressful.
  6. Mr X would like an acceptance of errors, apologies and financial redress.

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The Ombudsmen’s role and powers

  1. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A (1), as amended).
  2. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
  3. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

  1. I discussed the complaint with Mr X and considered the information he provided in support of his complaint. I have also reviewed information provided by the Council and the Trust, including Mrs Z’s clinical records, needs assessments and daily care notes. We have carefully considered all the written and oral evidence submitted to us, even if we do not mention specific pieces of evidence within the decision statement.
  2. I shared this draft decision with Mr X, the Council and the Trust and they had an opportunity to comment. I have carefully considered the comments I received.

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What I found

Key legislation and guidance

NHS Quick Guide: Discharge to Assess

  1. Definition of ‘Discharge to Assess – ‘Where people who are clinically optimised and do not require an acute bed, but may still require care services, are provided with short term funded support to be discharged to their own home (where appropriate) or another community setting. Assessment for longer-term care and support is then undertaken in the most appropriate setting and at the right time for the person.
  2. Principles for Discharge to Assess model include:
    • ‘Supporting people to go home should be the default pathway, with alternate pathways for people who cannot go straight home.
    • Putting people and their families at the centre of decisions, respecting their knowledge and opinions and working alongside them to get the best possible outcome.
    • Take steps to understand both the perspectives of the patient and their carers… [and] their needs…’

National Institute for Health and Care Excellence (NICE) guidelines for Falls in older people: assessing risk and prevention

  1. ‘Ensure that any multifactorial assessment identified the patient’s individual risk factors for falling in hospital that can be treated, improved or managed during their expected stay. These may include:
    • cognitive impairment
    • continence problems
    • falls history, including causes and consequences (such as injury and fear of falling) …
    • health problems that may increase their risk or fall
    • medication’
  2. ‘Ensure that any multifactorial intervention:
    • promptly addresses the patient’s identified individual risk factors for falling… and
    • takes into account whether the risk factors can be treated, improved or managed during the patient’s expected stay.’
  3. ‘Do not offer falls prevention interventions that are not tailored to address the patient’s individual risk factors for falling.’

Care Quality Commission guidance for Regulation 10: Dignity and respect

  1. 10.1 ‘Service users must be treated with respect and dignity. People using the service must not be neglected or left in undignified situations such as those described in the guidance for Regulation 13(4) below.’

Care Quality Commission guidance for Regulation 13: Safeguarding service users from abuse and improper treatment

  1. 13.4(c) ‘Providers and staff must take all reasonable steps to make sure that people who use the services are not subjected to any form of degradation or treated in a manner that may reasonably be viewed as degrading, such as:
    • Not providing help and aid so that people can be supported to attend to their continence needs, and
    • Making sure people are not…left in soiled sheets for long periods.’

Care Quality Commission guidance for Regulation 14: Meeting nutritional and hydration needs

  1. ‘Provider 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 people’s nutritional and hydration needs’
  2. Where a person is assessed as needing a specific diet, this must be provided in line with the assessment. Nutrition and hydration intake should be monitored and recorded to prevent unnecessary dehydrations, weight loss or weight gain.
  3. Staff must follow the most up-to-date nutrition and hydration assessment for each person and take appropriate action in people are not eating and drinking properly. Staff should know whether specialist nutritional advice is required and how to access and follow it.’

NHS Guidance for commissioners: Interpreting and Translation Services in Primary Care

  1. ‘Principle 1:4 Language preferences and communication needs should be recorded in the patient’s record…a highly visible alert should be used to ensure staff aware of a patient’s needs.
  2. Principle 4:6 patients should always be offered a registered interpreter. Reliance on family, friends or unqualified staff is strongly discouraged and would not be considered good practice.
  3. Principle 4:9 Professionals and primary care staff may use their language and communication skills to assist patients in making appointment or identifying communication requirements, (language brokering) but should not, other than where immediate and necessary treatment is required, take on the role of an interpreter unless this is part of their defined job role and they are qualified to do so.
  4. 2:2 Whilst not being able to speak English is not a ‘protected characteristic’ defined in the Equality Act 2010, section 13G of the National Health Service Act 2006 states that NHS England ‘in the exercise of its functions, must have regard to the need to reduce inequalities between patients with respect to: their ability to access health service; and the outcome achieved for them by the provision of health services.’

The Care and Support Statutory Guidance

  1. ‘3.30 Some groups in need of information and advice about care and support may have particular requirements. Local authorities must ensure that their information and advice service has due regard to the needs of these people. These include, but are not limited to:
    • People who do not have English as their first language.
  2. 6.23 From this early stage local authorities should consider whether the individual would have substantial difficulty in being involved in the assessment process and…….should also consider whether a person may have difficulty communicating and whether a specialist or interpreter may be needed to support communication.
  3. 9.23 Under the Care Act, local authorities have responsibilities to provide information and advice about people’s care and support.
  4. 9.32 Local authorities must provide this information and advice in formats that ensure compliance with the requirements of the Equality Act 2010 (in particular, they must ensure where appropriate that the information is accessible to...people for whom English is not their first language).’

What happened

  1. On 22 December 2019, following a collapse, Mrs Z was admitted to Blackburn Royal Hospital. She was diagnosed with an acute stroke and a fractured arm.
  2. Mrs Z’s discharge was planned by the Integrated Discharge Team, which is made up of both health and social care staff. The Integrated Discharge Team felt that Mrs Z would benefit from a short-term care placement in a care home so her longer term care needs could be assessed. Mr X initially wished for his mother to be discharged home but later agreed to the short-term care placement.
  3. On 27 January 2020, the social worker completed Mrs Z’s initial care assessment prior to her discharge to a care home. Referrals were to be made to physiotherapy, occupational therapy (OT), speech and language therapy (SALT), dieticians and the Community Stroke Team.
  4. On 7 February 2020, Mrs Z was discharged to the Care Home. A wheelchair should have transferred with her but this did not happen.
  5. On 14 February, the Community Stroke Team, Mrs Z’s social worker and an Urdu speaking social worker visited Mrs Z at the Care Home to complete a physiotherapy assessment. The Urdu speaking social worker attended the assessment to act as an interpreter. Mrs Z only speaks Punjabi. The Trust’s records note that Mrs Z was reluctant to engage with the exercises and therefore a full assessment could not be completed. The Community Stroke Team planned to return and complete a joint physiotherapy and OT assessment.
  6. Mrs Z started to become increasingly distressed when taken to her room and refused to sleep in her bed. Instead, Mrs Z preferred to sleep in a chair in the communal lounge.
  7. On 28 February, the Community Stroke Team carried out a joint physiotherapy and OT assessment of Mrs Z. No interpreter was present, with the Stroke team’s records noting that the OT could ‘speak some Urdu’. The assessment had been bought forward after the Care Home raised concerns that they were struggling to transfer Mrs Z. The assessment noted that Mrs Z had variable ability to transfer from her chair and often required the assistance of two staff members. She also had swelling in her legs, contributed to by her unwillingness to sleep in her bed. It was advised that Mrs Z sleep with her legs raised.
  8. On 10 March 2020, a multidisciplinary meeting took place and agreed a plan for Mrs Z to be discharged to her son’s home on 13 April with a package of domiciliary care.
  9. On 13 March, Mrs Z had an unwitnessed fall in the night. The Care Home night team found Mrs Z on the floor of the lounge. The Care Home checked Mrs Z for injury and sought advice from a GP via a 24-hour medical advice telephone service. They were advised to monitor Mrs Z for signs of concussion. The Care Home did not contact Mr X.
  10. The next day Mr X visited the Care Home and noticed Mrs Z had bruising to her face. He raised concerns with the manager that he had not been contacted immediately about the fall. Mr X strongly felt Mrs Z needed to go to hospital for an x-ray. The Care Home sought further GP telephone advice and were again told to monitor Mrs Z and give pain relief.
  11. Remaining concerned, Mr X contacted a senior nurse practitioner from the local GP Practice, who visited the Care Home to check Mrs Z. The nurse advised there was no clinical need to take Mrs Z to hospital. Mr X raised a safeguarding concern with the Council about Mrs Z’s fall.
  12. On 17 March, the Community Stroke Team’s OT visited Mrs Z’s son’s home. It was found to be a suitable location for discharge, although there was still some outstanding work to be done, such as clearing out some rooms to make more space for equipment and safe transfers.
  13. On 1 April 2020, the Council concluded its safeguarding enquiry. It found that the Care Home had sought appropriate medical advice. However, the safeguarding enquiry found the Care Home had not contacted Mrs Z’s family in a timely fashion. The Council also found the Care Home had not adhered to its falls protocol but that this did not have a significant impact on Mrs Z’s care. The Council emphasised the importance of good communication and following local policy and procedure.
  14. On 13 April, Mrs Z was discharged to her son’s home with a care package.



Mrs Z’s wheelchair

  1. Mr X complains that the Trust did not transfer Mrs Z’s wheelchair with her when she was discharged to the Care Home. In its complaint response, the Trust accepted that the wheelchair should have travelled with Mrs Z however this did not happen due to a communication error. The Trust apologised to Mr X for the delay and said it has spoken with the staff involved.
  2. The failure of the Trust to transfer Mrs Z’s wheelchair to the Care Home is fault. However, I have seen nothing to suggest the delay in providing a wheelchair had a significant impact on Mrs Z. The Trust has already accepted this error, apologised and taken steps to address it. I have seen nothing to suggest that this is a wider issue. I am satisfied that the Trust has taken appropriate actions to put things right.

Failure to involve family in discharge arrangements

  1. Mr X complains that he was not involved in choosing which care home Mrs Z would be discharged to, and that Mrs Z was discharged without the date and location being discussed with him before the decision was made.
  2. As mentioned above, there was initially some disagreement between Mr X and the Integrated Discharge Team about Mrs Z’s discharge location. However, it was agreed that Mrs Z would go to a short-term placement in a care home. During the multidisciplinary meeting, a specific care home was suggested. However, on 29 January 2020, this care home advised the social worker that it was unable to accept Mrs Z. The social worker’s case notes records that she telephoned Mr X to update him about this.
  3. There is no further information in the social worker’s case notes about how Mrs Z’s discharge location was arranged. However, it appears the Care Home placement was offered on, or around, 6 February.
  4. The Council’s records note that social worker called Mr X several times on 6 and 7 February but was unable to get through. Mr X disputes this and says he did not receive any calls or notifications of missed calls on his mobile phone. Further investigation is unlikely to satisfactorily resolve this point.
  5. The social worker successfully spoke to Mr X in the afternoon of 7 February and told him Mrs Z would be discharged to the Care Home later that day.
  6. There is no evidence in the case records to show that the Trust or the Council discussed Mrs Z’s discharge location with Mr X until 7 February, by which the point a decision had already been made. This was not in keeping with the principles of the Discharge to Assess model and represented a failing on the part of the Trust and Council. This caused Mr X frustration and uncertainty.

Delayed needs assessment

  1. Mr X complains that Mrs Z was discharged without a care needs assessment or care plan in place, and this was not completed for weeks.
  2. Mrs Z was discharged to a Discharge to Assess placement. This means that she was medically fit for discharge, but more time was needed to properly assess her needs for longer term care. As such, her needs would not have been fully assessed in hospital, prior to her discharge. The Council records show that an initial care needs assessment for Mrs Z was completed on 27 January 2020. This was completed in a timely manner and I have not seen any evidence of delay.
  3. The Council also completed a further care needs assessment on 5 May 2020, shortly after Mrs Z had moved to her son’s house. We would usually expect care assessments to be completed within six weeks. While finalising this assessment took a little longer than that, there is evidence Council officers were actively working on, and updating, the care assessment throughout Mrs Z’s stay in the Care Home. Again, I have not found any evidence of undue delay.
  4. However, it does not appear that these assessments were shared with Mr X, and therefore he was unaware that they had been completed. It would have been good practice to have shared these documents with him. This is a further failure by the Council to adequately involve Mr X in decisions surrounding Mrs Z’s care, which caused him frustration.

Poor care by the Care Home – Missing records

  1. As part of my investigation, I requested the daily care records for Mrs Z’s time in the Care Home. I was provided with the records for 7 to 29 February 2020. Unfortunately, the Care Home has been unable to locate the daily care records for March or April 2020. The Care Home explained that it experienced a flood in its archive in 2021. This destroyed many records. The Care Home said it is possible Mrs Z’s records were destroyed at this time, though it could not confirm this.
  2. The lack of records has impacted on my ability to fully review Mrs Z’s care during March and April 2020. While I appreciate that unpredictable events, such as floods occur, it is concerning that the Care Home have only been able to speculate that this is what might have happened to Mrs Z’s records. They have not been able to confirm this, and simply do not know where the records are. This is fault. This will cause understandable uncertainty and frustration for Mr X, who is unable to obtain answers to some of his questions due to lack of records.

Poor care by the Care Home – Lack of supervision and fall management

  1. Mr X complains that Mrs Z was not properly supervised by the Care Home and was left alone for long periods. The daily care records note that she was ‘checked regularly’ and Mrs Z mostly chose to spend her time, and often her nights, in the communal lounge where staff could easily observe her. I have not found any evidence to suggest that Mrs Z was not properly supervised.
  2. Mr X further complains that Mrs Z was allowed to walk around unsupervised, leading to falls. The records show that Mrs Z had at least two falls, one on 9 February 2020 where she had an unwitnessed fall out of bed, but was found laughing and was uninjured. She also had a further unwitnessed fall on 13 March 2020, resulting in bruising to her face. There were also occasions where Mrs Z was seen sitting herself on the floor, although she had not fallen and did not suffer any injuries.
  3. It is clear from the records that Mrs Z was sometimes confused and did not always wish to comply with instructions. The Council’s complaint response describes Mrs Z as 'strong willed' and says she sometimes sought to mobilise independently.
  4. I asked the Council about what steps were put in place to mitigate Mrs Z’s risk of falling. I have also reviewed the Care Home’s fall risk assessments and plan. The records show that the Care Home reviewed Mrs Z’s fall risk on three occasions, identifying her as ‘High Risk’ of falls each time. This included reviewing her risk immediately after her falls. The Council explained that Mrs Z’s profiling bed had been placed on the lowest setting and a crash mat was in place by her bed. It is not entirely clear from the records, but there are also references to a sensor mat being ordered for Mrs Z.
  5. It is not always possible for a Care Home to prevent a person mobilising independently nor for any resident to be supervised constantly without 1:1 care in place. It is also not possible to completely eliminate the risk of falls. Instead, care providers are expected to assess an individual’s risk of falling and then take appropriate steps to reduce the risk of falling as much as is practically possible.
  6. The Care Home properly assessed Mrs Z’s risk of falls and took appropriate steps to mitigate the risk by with equipment in her bedroom and staff monitoring. It would have been impractical for the Care Home to install additional equipment in the lounge area, as this could have increased the risks for other residents by introducing trip hazards. I have not found fault with the way Mrs Z’s risk of falling was managed.

Poor care by the Care Home – Suitable sleeping arrangements

  1. Mr X complains that the Care Home did not do enough to find suitable alternate sleeping arrangements for Mrs Z when she refused to sleep in her bedroom. The records show that Mrs Z became increasingly distressed when taken to her room and displayed a strong preference to remain in the lounge area overnight. This meant she spent a number of weeks sleeping in a chair, instead of a bed, which contributed to oedema (fluid build up and swelling) forming in her legs.
  2. Mr X asked the Care Home to providing a recliner chair for Mrs Z. This was declined by the physiotherapist, as Mrs Z had attempted to stand from a recliner chair and therefore it created a falls risk. Instead, Mrs Z would sleep in a regular armchair, with her feet raised on a footstool. I have not found any fault with this decision, which has been explained to be the safest and most appropriate option.
  3. It was not possible for Care Home staff to insist that Mrs Z remain in bed when she refused to do so. The records show Mrs Z became increasingly upset at attempts to take her to her room. The records I have seen show that staff made regular efforts to encourage Mrs Z to go to bed in her room, and eventually Mrs Z did begin to accept sleeping in her bed. I am satisfied that the staff sought to find the balance between supporting Mrs Z properly and not causing her excessive distress. Ultimately, the best solution was for Mrs Z to sleep in her bed and there is evidence that the Care Home staff were actively working to achieve this. I have not found fault with the way the Care Home staff managed her sleeping arrangements.

Poor care by the Care Home – Oedema management

  1. Mr X complains about the way Mrs Z’s oedema was managed. He says failure to ensure Mrs Z was mobilising regularly caused the swelling. I have not seen evidence to confirm that the amount the Care Home assisted Mrs Z to mobilise was the sole cause of her oedema. It is not possible to determine the exact cause. There were various contributing factors to Mrs Z developing oedema in her legs, including sleeping in a chair following her refusal to sleep in her bed and her general reduced mobility following her stroke. Further, Mrs Z was not always compliant with attempts to raise her legs while sitting and sleeping. The records show that the Senior Nurse Practitioner from a local GP Practice raised concerns about swelling in Mrs Z’s legs and asked that her legs be raised more frequently. The nurse wished to avoid medication as its effect could also increase the risk of falls.
  2. The daily care records for February 2020 show some references to Mrs Z’s legs being raised following requests from the nurse, and that the oedema improved following this. When Mr X remained unhappy about Mrs Z’s legs, the Care Home contacted a GP, who prescribed a short course of water tablets. There is evidence that the Care Home was taking action to address the oedema. Overall, I have not found fault on this point.

Poor care by the Care Home – Nutrition and hydration

  1. Mr X complains that the Care Home failed to properly thicken Mrs Z’s food and drinks. I have reviewed Mrs Z’s Support Plan for Eating and Drinking which lays out Mrs Z’s requirements in detail. It includes the Speech and Language Therapist’s (SLT) recommended thickness levels and instructs staff to ensure her food and drink is mixed as recommended. It Is clear that the Care Home was aware of Mrs Z’s requirements, had assessed her risks and put an appropriate plan in place to support her nutrition and hydration.
  2. I have seen nothing in the records to suggest that Mrs Z’s food and drink was not properly thickened. I acknowledge Mr X’s recollection of conversations with staff where he says they were not aware of the requirement, however I have not seen persuasive evidence to support this. There is no record of Mrs Z’s experiencing any episodes of choking or aspirating during her stay at the Care Home and records indicate that her swallow improved during this period. On the balance of probabilities, I am satisfied that Mrs Z’s hydration and nutrition was managed properly and in line with the relevant guidance.

Poor care by the Care Home – Medication management

  1. Mr X also raises concerns that the Care Home did not crush Mrs Z’s medication. I asked the Care Home about this and they replied that they had not received any instructions that Mrs Z’s medication needed to be crushed. I have reviewed the Trust’s documents, including Mrs Z’s prescription list and the Speech and Language (SLT) assessment, and there is no reference to Mrs Z requiring her medication to be crushed. I have not seen any evidence of fault by the Care Home on this point.
  2. I acknowledge Mr X’s recollection that Mrs Z required her medication to be crushed. However, I have not seen anything to suggest that uncrushed medication had any impact on Mrs Z’s wellbeing.

Poor care by the Care Home – Handling Mrs Z’s fractured arm

  1. Mr X says Mrs Z told him that Care Home staff had been hitting her. Mr X did not think this was the case, but was concerned that staff members may have inadvertently caused Mrs Z pain while dressing her due to being unaware that she had a fractured arm. Mr X raised concerns with the Care Home and I have reviewed these records. The Care Home notes show it was fully aware of Mrs Z’s fractured arm as this was noted in the Trusted Assessment document which it received from the Trust as part of Mrs Z’s discharge. Mrs Z’s fracture is also referenced multiple times in her care plan and mobility plan, including the need for staff to be mindful of her arm and possible pain. The management discussed Mr X’s concerns with the staff in question immediately after he raised them and contemporaneous notes demonstrate that the staff said they were aware of the fracture.
  2. Mrs Z had fluctuating capacity and has raised a number of allegations of being hurt by various people, which safeguarding enquiries concluded were unfounded. Mr X did not raise a safeguarding concern about this incident and I cannot say whether staff had accidentally hurt Mrs Z’s arm. I acknowledge Mr X’s recollection of conversations with staff, who he says were unaware of Mrs Z’s fracture but there is no further evidence to confirm this. The records suggests that the Care Home was fully aware of Mrs Z’s fracture and had taken steps to ensure staff were aware of this and were mindful of this when handling Mrs Z and monitoring her pain levels.

Poor care by the Care Home – Pressure care

  1. Mr X complains that the Care Home failed to provide a pressure cushion for Mrs Z’s wheelchair. A pressure ulcer risk assessment completed by the Trust found Mrs Z to be at moderate risk of pressure damage. This required some preventative measures to be put in place, such as providing a pressure relieving cushion. In its complaint response, the Care Home accepts that Mrs Z was not always moved from her wheelchair soon enough and should have been provided with a pressure relieving cushion. This is fault. However, there is no evidence that Mrs Z suffered any pressure damage as a result and therefore any injustice to Mrs Z is limited. The Care Home took appropriate steps to rectify the issue once raised by purchasing a pressure cushion.

Poor care by the Care Home – Continence care

  1. Mr X complains about that Mrs Z’s personal hygiene care was inadequate and that she was often wet when he visited her. Mrs Z had a catheter in place when she was in hospital and during discharge. The catheter was removed shortly after her arrival at the Care Home. Therefore, the extent of her incontinence would not have been apparent prior to discharge. However, once the catheter had been removed, it would have been clear that Mrs Z was frequently incontinent. At this point, appropriate steps should have been taken to manage this.
  2. As mentioned above, Mrs Z’s daily care records contain very little information about her continence care. The records mostly repeat the phrase ‘continence needs met’, with little or no further detail.
  3. The Community Stroke Team’s notes mentions Mrs Z’s incontinence during most of their visits. The team visited Mrs Z on four occasions between 28 February and 9 March 2020. Mrs Z was found wet on three of these visits. On the other visit, the carpet was wet from an earlier incontinence episode, although Mrs Z had been changed. On 6 March, the Community Stroke recorded that the Care Home were trying to get a urine sample to commence a continence assessment.
  4. At a case conference on 10 March, the Community Stroke Team raised concerns about the management of Mrs Z’s continence. The notes states ‘highlighted issue of incontinence and the fact [Mrs Z] is wet on our arrival and clothes are sodden. Staff at Care Home are conducting a continence assessment and will liaise with [District Nurse] re: appropriate continence products’.
  5. I have reviewed the Care Home’s communication sheets for visiting professionals and have not seen any evidence of the Care Home discussing Mrs Z’s continence needs with the visiting nurses. By 10 March, Mrs Z had been resident in the Care Home for a month and a continence assessment still had not been completed. This is fault.
  6. I am not persuaded that the Care Home records available sufficiently demonstrate that Mrs Z was receiving appropriate continence care. I have also taken into account Mr X’s concerns and the Community Stroke Team’s observations. I acknowledge that episodes of incontinence cannot always be avoided. However, it appears that Mrs Z was being found in wet clothes on a regular basis. I have found that the Care Home failed to properly meet Mrs Z’s continence needs. This is not in line with the CQC’s guidance Regulation 10 for dignity and Regulation 13 for safeguarding. This would have impacted on Mrs Z’s dignity and caused her unnecessary discomfort. Mr X was also caused upset and concern.

Poor care by the Care Home – Medical attention following a fall

  1. Mr X complains that the Care Home failed to seek appropriate medical attention for Mrs Z’s injuries, following her fall on 13 March which left her face bruised. Mr X strongly feels that Mrs Z should have been taken to hospital for a face-to-face examination and an x-ray, given that a head injury was involved.
  2. The fall occurred during the first COVID-19 lockdown in March 2020. The Care Home says that it was best to avoid hospital visits during the pandemic unless clinically necessary. The Care Home contacted a 24-hour telephone service twice to obtain GP advice. Both times, the advice was to provide Mrs Z with pain relief and monitor her for signs of concussion.
  3. At Mr X’s request, a Senior Nurse Practitioner also visited the Care Home to check Mrs Z. The nurse was also of the view that Mrs Z did not require a hospital visit. I have not seen any evidence to suggest that Mrs Z developed concussion or had any other injuries beyond the bruising which would have required medical attention.
  4. As such, I have not found fault with the way the Care Home treated Mrs Z following the fall. I note that the Council’s safeguarding enquiry found that the Care Home had failed to follow their Falls Policy as certain documents had not been completed. However, the Council found that this had not impacted on Mrs Z who had received appropriate care and observations. I agree with the Council’s findings.

Poor care by the Care Home – Communication

  1. Mr X complains that the Care Home failed to properly communicate with him and the manager ‘lied’ in their complaint response by saying the family was involved. There have been some clear communication failures, the most serious relating to Mrs Z’s fall on 13 March. The Care Home has already accepted that Mr X should have been advised sooner that his mother had fallen. Failure to do so caused Mr X upset and worry. The Care Home has apologised to Mr X and explained that their handover documents have been improved. Further, the Care Home has implemented a new electronic system which provides family with real time updates about the resident’s care. Overall, the Care Home has taken reasonable steps to put things right, however I will outline below where I recommend further work can be done to improve communication with relatives.
  2. I have also reviewed the Care Home’s family communication records. There are no records after 14 March, so again there may be some records missing. The available records mostly show Mr X raising concerns and the Care Home responding. There is little evidence in the records to suggest that the Care Home proactively communicated with Mr X. This is fault and caused Mr X frustration.

Physiotherapy assessments

  1. Mr X complains that there was a delay providing Mrs Z with physiotherapy once she moved to the Care Home. He says she went almost a month without any physiotherapy support.
  2. He also complains that his mother was not provided with a Punjabi speaking interpreter during her assessments. He says an unqualified member of staff, who did not speak the same language as Mrs Z, was used instead. Mr X feels this impacted on Mrs Z’s ability to participate with the assessments successfully and contributed to the delay
  3. The Community Stroke Team received Mrs Z’s referral on 10 March, three days after she was discharged. The Community Stroke Team aim to schedule an appointment within five working days. The physiotherapist visited Mrs Z on 14 February 2020 to complete an initial assessment, within this timescale. The physiotherapist could not complete the assessment as Mrs Z was unable to participate in some of the exercises. The physiotherapist decided to repeat the assessment at a later date, completing a combined assessment with an OT.
  4. The Trust and Council were aware that Mrs Z only spoke Punjabi. Despite this, they failed to provide her with an appropriate interpreter for this assessment. Instead, an Urdu speaking social worker attended to act as an interpreter.
  5. The physiotherapist returned with the OT on 28 February to complete a further assessment. The Trust said that the 14-day wait between assessments was due to a short waiting list and staff availability. I note that the assessment was brought forward by a few days after the Care Home raised concerns that they were struggling to transfer Mrs Z. The Trust explained that there was no Early Intervention Pathway or urgent care pathway, at the time.
  6. Again, the Trust did not provide an interpreter for Mrs Z. Instead, the Community Stroke Team relied on non-verbal cues and assistance from the OT who could speak ‘some Urdu’.
  7. In addition to her language requirements, Mrs Z had some cognitive difficulties impacting on communication. As such, the importance of clear communication, particularly during assessments, was vital. Given that the previous assessment had been unsuccessful at least in part to cognitive and communication problems, the Trust should have provided a Punjabi speaking interpreter to support Mrs Z at the second assessment.
  8. The failure to provide Mrs Z with an appropriate Punjabi speaking interpreter during both assessments meant the Trust did not provide care and support that was in keeping with the relevant NHS guidance or the Care and Support Statutory Guidance. This is fault.
  9. I note that the physiotherapist visited Mrs Z promptly to conduct the initial assessment was completed promptly, however it could not be completed on the date and had to be repeated two weeks later. Mr X has been left with uncertainty about whether failure to provide an interpreter exacerbated the communication difficulties during the assessments and caused additional delay. This has also caused frustration for Mrs Z and Mr X.
  10. Following my enquiries, the Trust said it has introduced a new policy in relation to interpreters. However, the Trust did not provide any evidence of this, such as a copy of the policy. As such, I have been unable to satisfy myself that the new policy adequately addresses the concerns raised.

Safeguarding enquiry

  1. Mr X complains that the Council failed to take appropriate action following his safeguarding concern about his mother’s fall. On 1 April 2020, the Council completed their safeguarding enquiry. The Council found that Mrs Z’s care had been appropriate. The Care Home’s fall policy had not been followed as some documents had not been completed, however found this had not impacted on the care Mrs Z received. The Council issued actions reminding of the importance of good communication with and following local policy and procedure.
  2. Mr X considers that stronger action should have been taken as a result. It is not the purpose of the safeguarding process to take punitive action against providers. I have not found fault with the way the Council completed its safeguarding enquiry. The Council considered Mr X’s concerns in detail and has recommended proportionate actions.

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Agreed actions

  1. Within one month of my final decision, the Trust and the Council will apologise to Mr X and Mrs Z for identified failings
  2. Within one month of my decision, the Trust and the Council will pay Mr X a total of £250 for distress and uncertainty
  3. Within one month of my final decision, the Council will pay Mrs Z £200 for failings in her continence care
  4. Within three months of my final decision, the Council and the Trust will review the integrated discharge procedures to ensure this provides clear guidance for staff on the importance of involving carers and relatives in the discharge process.
  5. Within three months of my final decision, the Council and the Trust with review their policies in relation to providing interpreters for people who do not speak English as their first language.
  6. Within three months of my final decision, the Council will explain what action it will take to ensure the Care Home
    • reviews its archiving methods to minimise the risk of records before lost and has a system in place to record any known missing records,
    • reviews its continence care policy including timescales for completing continence care assessments; and
    • ensures it has clear guidance in place for staff regarding timely and appropriate communication with families.

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Final decision

  1. I found that the Trust and the Council failed to adequately involve Mr X in choosing the discharge location for Mrs Z.
  2. The Council and the Trust also failed to provide an appropriate interpreter for Mrs Z during her physiotherapy and OT assessments.
  3. I found fault by the Council in relation to record keeping, communication with Mr X and Mrs Z’s continence care.
  4. I am satisfied that the Council and Trust have agreed to provide reasonable and appropriate remedies for the injustice caused to Mr X and Mrs Z. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman

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