Summary: Mrs X complained about the care her father received and the accuracy of notes that were taken while he was resident in a care home. Mrs X said the poor care meant her father’s health deteriorated rapidly. We find the Care Provider at fault for failing to take and keep accurate records. We recommend the Care Provider apologise to Mrs X, make a payment for uncertainty and distress, and remind its staff of the need to take accurate records going forward.

The complaint

1. Mrs X complains about the care her father, Mr Y, received while resident at a care home for two weeks’ respite care. Mrs X says the care home did not give her a copy of Mr Y’s care plan before he entered the care home and the records from his stay are inaccurate and incomplete. Mrs X says Mr Y’s health deteriorated because of the poor care he received while in the care home.

Back to top

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. (Local Government Act 1974, sections 34B and 34C)
3. We consider whether there was fault in the way an organisation made its decision. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
4. 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)
5. 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.

Back to top

How I considered this complaint

6. I spoke to Mrs X and considered all the information she has provided. I also considered all the information the Care Provider has provided.
7. Mrs X and the Care Provider had an opportunity to comment on a draft decision and I considered the responses received before reaching this final decision.

Back to top

What I found

Care home regulation and guidance

8. 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.
9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC had guidance on how to meet the fundamental standards.
10. The CQC issues guidance on the regulations.
11. In respect of Regulation 9 it says care providers must actively seek the views of people who use their service and those lawfully acting on their behalf, about how care and treatment meets their needs. Providers must be able to demonstrate they acted in response to any feedback.
12. In respect of Regulation 17, it says care providers must maintain accurate, complete, and detailed records for each person using their service.

What happened

13. Mr Y suffered with dementia and entered a care home, Skylark House, for two weeks’ respite care in July 2021. This was arranged by Mrs X, who held Lasting Power of Attorney for Health and Welfare for Mr Y. Mrs X said when Mr Y arrived at the care home, he could walk with the aid of a walking frame and use the toilet unaided.
14. The care home completed a pre-admission form for Mr Y on 9 July 2021.The pre-admission plan completed for Mr Y recorded that he needed help with his mobility as he required a zimmer-frame but often forgot to use it. It also recorded Mr Y needed help with dressing and personal hygiene and he had incontinence issues.
15. Mr Y entered the care home on 12 July 2021. Staff then completed a Resident Care Plan based on his pre-admission form and observations within 72 hours of his arrival.
16. The Resident Care Plan stated Mr Y was entering the care home for two weeks’ respite care with the aim of recuperating and returning close to his previous levels. The care plan noted Mr Y should always have fresh water in his room with a glass of water within reach. It also noted Mr Y should be helped to use the toilet and maintain his personal hygiene. It said staff should help Mr Y to walk in the garden after his isolation and that his TV should be working as he loves to watch the news. It confirmed Mr Y could mobilise himself and walk using a zimmer-frame if he was supported by one carer.
17. The section at the end of the Resident Care Plan for noting objections or comments was blank. As was the section for signatures of the resident or their representative and the care manager.
18. The nutrition and fluid notes from the duration of Mr Y’s stay at the care home show he was observed to be eating meals well and regularly having drinks.
19. Welfare records show staff checked on Mr Y hourly throughout his stay at the care home and offered him drinks regularly. They also record Mr Y’s nutrition and toilet needs were observed and he took part in ‘meaningful activity’.
20. The care notes, completed daily during Mr Y’s stay, show staff regularly observed him eating and drinking well and mobile. They show Mr Y spent a lot of time in his room, but also visited other areas of the care home, such as the dining room and the garden. The notes show staff regularly assisted Mr Y with tasks such as using the toilet and the call bell was always within easy reach. However, the notes also contain contradictory information and refer to Mr Y being held in isolation.
21. Mrs X has said, during a visit on 23 July, she noticed Mr Y was much less mobile than usual and raised this with the care home. The Care Provider says the care home noted Mr Y was more sleepy than usual but attributed this to particularly hot weather that week and other residents had similar symptoms. The Care Provider also says the nurse Mrs X raised her concerns with checked Mr Y, but she did not note anything concerning.
22. The daily care notes for 23 July explain Mr Y had his meals and drinks in his room, was helped to the toilet, and was visited by family. They do not mention the nurse’s check of Mrs X’s concerns or anything unusual about Mr X’s mobility.
23. The notes suggest Mr Y was still mobile with the use of his zimmer-frame and the help of one carer throughout his time at the care home. The notes state Mr Y had lost 5kg during his time at the care home and he left to return home as planned on 26 July.
24. Mrs X wrote to the care home on 28 July. She explained:
• Mr Y’s GP had confirmed Mr Y suffered a Transient Ischaemic Attack (or a ‘mini stroke’) while he was at the care home.
• The care home never provided a copy of Mr Y’s care plan, even though they had asked for this. Mrs X asked for a copy of this, daily care records, and information about the care home’s complaint process.
• Mr Y was dropped home without his walking frame and asked for the care home to return this.
25. Following discussion with the Care Provider, Mrs X complained about Mr Y’s stay at the care home. Mrs X said:
• Mr Y lost mobility during his stay at the care home and there was a notable deterioration in his health from 23 July 2021. Mrs X said Mr Y’s mobility deteriorated so badly he was barely able to move himself at all when he left the care home. She felt staff should have picked up on that and taken action to assess it.
• The care home manager did not return her or her mother’s calls when she asked for updates on Mr Y.
• The care home did not give her a copy of Mr Y’s care plan until he left the care home. If it had done, she would have been able to correct the inaccuracies it contained. For example, the date of Mr Y’s Alzheimer’s diagnosis was wrong and the objective of him recuperating was not realistic. It also noted Mr Y loved watching the news and this was wrong as he hated watching anything with conflict or trouble and found the news distressing.
• The care notes raised questions about the care Mr Y received. He should never have been in isolation, there was no reason to offer him high calorie snacks, they wrongly stated he could walk unaided. The care notes also said Mr Y established a good relationship with other people but Mrs X felt this was wrong as he does not understand almost everything communicated with him. The notes also constantly refer to a call bell being close, but this was no good because Mr Y would not have known how to use it.
26. The Care Provider responded to Mrs X on 26 October. It explained:
• Mr Y’s pre-admission assessment showed he could walk small distances with a walking frame but needed a lot of assistance. Mr Y’s GP had confirmed his mobility was very poor in June 2021, prior to his stay at the care home. While he was at the care home, Mr Y needed a lot of encouragement to mobilise but did move around slowly throughout his time there.
• Staff observed Mr Y was more sleepy than usual on 23 July, but they put this down to it being a very hot week and other residents were also less mobile. As this was a Friday and Mr Y was due to return home on the Monday, the staff did not refer him for further assessment. However, if Mr Y had stayed longer, staff would have raised this on the next GP round if no improvement was observed.
• The home manager checked on Mr Y when she said she would but did not recall promising a phone call and did not receive any more messages from Mr Y’s family.
• Mrs X did not request a copy of Mr Y’s care plan or it would have provided this, however the Care Provider was sorry if it did not explain this on admission. It also agreed there were some errors in the notes. It agreed the expected result of Mr Y’s recuperation was unrealistic, but this did not have an impact on the care he received. It also agreed it had recorded the date of Mr Y’s Alzheimer’s diagnosis wrongly. However, recording the date is not a requirement, it only needs to know how to support residents, so this would not have impacted the care Mr Y received. It was not clear where the information about Mr Y enjoying watching the news came from and it could not establish if he did watch the news during his stay. The Care Provider agreed the care plan was misleading and not helpful here.
• Mr Y was not in isolation and the daily notes showed he was often outside of his room. It is not clear why the notes suggested he was isolating, and the Care Provider was sorry for the misleading information. Mr Y ate most of his meals in the dining room, was encouraged to join activities, and spent time out in the garden.
• Records show Mr Y went for walks in the garden and engaged with residents and staff to the best of his ability. He was also able to express his own wishes on whether he wanted to stay in his room.
• The care home offers all residents high calorie snacks unless they need a reducing diet. Mr Y also always had access to fluids and staff made efforts to ensure he kept hydrated.
• Mr Y could move himself in bed during his stay at the care home.
• Before he entered the care home, Mr Y was only able to bear weight temporarily and needed a wheelchair during his admission as he was struggling to walk. Wheelchairs were only ever used for longer distances. Care staff confirmed Mr Y could use the stairs, but it would not be safe or quick for him to use them in the event of an evacuation.
• The call bell is a requirement unless it deems it as a risk to the resident. The call bell is also for staff and visitors should they need attention.
• There were no concerns about Mr Y through the duration of his stay and it was only the last few days when Mrs X noticed a decline. However, staff had checked his blood pressure and responses and were not concerned or felt it warranted an out of hours call. In hindsight, it may have been helpful to check with Mrs X’s mother if she was happy with the assessment or if an emergency visit would have provided assurances.
• There were shortfalls with the care plan documents that it should have picked up earlier. The Care Provider apologised for this and explained it had addressed this within the team.
• If Mrs X remained unhappy, she would be free to bring her complaint to the Ombudsman.
27. Mrs X brought her complaint to the Ombudsman on 23 March 2022.
28. The Care Provider has told us:
• It does not send care plans before admission as they are put together once a resident is admitted and a 72-hour assessment has taken place. It said it shares care plans on request, but Mrs X did not request Mr Y’s care plan until he had been discharged.
• There are no records of formal concerns being raised until after Mr Y was discharged.
• Although Mr Y’s family did flag his condition with the nurse on duty on 23 July 2021, he was checked and this was put down to it being a particularly hot week. Other residents were also affected at this time.
• It accepted there were inconsistencies in its record keeping and apologised for this. It has now learned lessons from this error.

Analysis

Quality of record keeping

29. The Care Provider has recognised its record keeping has been inaccurate on the pre-admission form and care plan, and the daily care notes. This is fault and not in line with CQC guidance on Regulation 17.
30. The Care Provider has said the errors on the pre-admission forms did not affect the care Mr Y received. However, this would still have caused significant uncertainty and distress for his family as it casts doubt on the understanding of his situation.
31. My view is the Care Provider could have avoided this situation if it had ensured the Resident Care Plan was checked and signed off by Mrs X, in line with CQC guidance on Regulation 9. I find the care home at fault for not sharing the document with Mrs X.
32. The Care Provider has also said the daily notes show Mr Y did receive adequate care despite errors, such as saying he was isolating when other notes show he was not. But my view is this would have caused further uncertainty for Mrs X and her family as it has left questions about what care Mr Y received and what else was inaccurate.
33. This uncertainty would have been increased by the fact the notes from 23 July do not make any mention of concerns being raised around Mr Y’s mobility or how this was assessed.

Level of care Mr Y received

34. It must have been distressing for the family to see Mr Y’s deterioration following his stay at the care home, however I cannot say this was a direct result of the care Mr Y received. I need to give the appropriate weight to the documentary evidence available to decide whether there is evidence of fault by the care home.
35. The nutrition and fluid charts suggest the care home consistently ensured Mr Y was eating and taking on fluid throughout his stay with them. The notes also show staff checked Mr Y hourly throughout his stay to monitor his wellbeing.
36. While there are errors in the daily care records, overall, they show the staff at the care home provided Mr Y with constant care while he was there.
37. There are absences of detail in the care notes, and on 23 July there is no reference to concerns that were raised or how they were assessed. However, a lack of records is not evidence of fault in the care given.
38. I do not find there is evidence of fault with the care given to Mr Y.
39. I appreciate Mrs X feels very strongly that the care home did not provide adequate care to Mr Y but the notes do not reflect this. Even when considering the inaccuracies in the records, I have seen no evidence of fault in the care home’s actions to find it at fault for providing poor care.

Back to top

Agreed action

40. To remedy the injustice identified above, I recommend the Care Provider, within one month:
• Apologise to Mrs X for failing to keep accurate records relating to Mr Y’s care.
• Pay Mrs X £250 to recognise the uncertainty and distress she would have been caused by the inaccurate care plan and care notes.
• Remind staff of the importance of keeping accurate, complete, and contemporaneous notes throughout a resident’s care and provide the Ombudsman with evidence of this.
• Remind staff of the importance of giving residents or their representatives the opportunity to comment or object to care plans and provide the Ombudsman with evidence of this.
41. The Care Provider has now agreed to these recommendations.

Back to top

Final decision

42. I find the Care Provider at fault for failing to take and keep accurate notes and records. I also find the Care Provider at fault for failing to give Mrs X an opportunity to comment on Mr Y’s care plan. I do not find fault with the level of care Mr Y was provided.
43. The Care Provider has agreed with my recommendations, and I have completed my investigation.

Back to top

Investigator's decision on behalf of the Ombudsman