Summary: Mr Y complains about the care delivered to his mother

The complaint

1. Mr Y complains about the poor standard of care which his mother received whilst resident at St Laura’s care home in 2021. He says the home’s failures directly contributed to Mrs Y’s ill health and general deterioration before her death.

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The Ombudsman’s role and powers

2. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
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. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. 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

6. During my investigation I discussed the complaint with Mr Y by telephone.
7. I made enquiries of the care provider and considered the information it provided alongside any relevant law or guidance as quoted in this statement.
8. I issued a draft decision statement and invited comments from Mr Y and the care provider. I considered any comments received before making a final decision.
9. 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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What I found

What should happen

Standards of care

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC is the statutory regulator of care services. It keeps a register of care providers that 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. Regulation 9 of the Health and Social Care Act 2008 says the care and treatment of service users must be appropriate, meet their needs, and reflect their preferences.
12. Regulation 12 sets out the requirement for care and treatment to be provided in a safe way for service users. This says a registered person must, amongst other requirements, do the following:
• assess the risks to the health and safety of service users receiving the care or treatment;
• do all that is reasonably practicable to mitigate any such risks;
• ensure that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.
13. Regulation 14 sets out requirements around the hydration and nutrition of service users. The guidance on this regulation says:
• Nutritional and hydration intake should be monitored and recorded to prevent unnecessary dehydration, weight loss or weight gain. Action must be taken without delay to address any concerns.
• Staff must follow the most up-to-date nutrition and hydration assessment for each person and take appropriate action if people are not eating and drinking in line with their assessed needs.
• Staff should know how to determine whether specialist nutritional advice is required and how to access and follow it.

COVID-19 visiting restrictions

14. On 17 May 2021 the Government announced care home residents could have up to five named visitors, up from the previous two visitors. In addition, visits to a care home will only have to pause for a minimum of 14 days rather than 28 days following an outbreak of COVID-19.
15. On 14 June 2021 the Government announced a further relaxation, with effect from 21 June 2021, allowing care home residents to leave the home to spend time away with family and friends. Every resident could nominate an essential care giver to give additional support during visits. Prior to this, residents could only leave the care home for a visit if outdoors or for high priority reasons (such as a dental or GP appointment). People admitted to a care home from the community would no longer have to self-isolate for 14 days on arrival having had tests before admission, on the day of admission and seven days after admission.

What happened

16. Mr Y’s mother, who I will refer to as Mrs Y, moved to St Laura’s Care home in June 2021. I will refer to this as ‘the home’ throughout this statement. In August Mrs Y was admitted to hospital after she became unwell at the home. Mr Y said his mother was diagnosed with Sepsis on her arrival and she sadly died in September. Mr Y complains the home failed to properly care for Mrs Y and that her sudden deterioration could have been avoided.
17. Mr Y also says that visiting restrictions imposed by the home meant that family were not able to identify a decline in Mrs Y’s health sooner.
18. I have reviewed the daily care records for the six weeks that Mrs Y was resident at the home. These reveal the following key events:
• When admitted to the home, notes say that Mrs Y was not settled and quite tearful. However, in the first few days Mrs Y ate and drank well.
• On 25 June Mrs Y was heard by staff to have fallen and complained of pain to the back of her head and to her right shoulder. This was later confirmed by CCTV footage. The staff called 999 and comforted Mrs Y. The ambulance arrived two hours later, and paramedics agreed it was necessary for Mrs Y to go to hospital due to her level of pain. The home called Mr Y to inform him about the fall and Mrs Y’s transfer to hospital. Tests conducted at the hospital did not show any significant concerns, other than a Urinary Tract Infection (UTI) and low potassium levels. Mrs Y returned to the home later that evening.
• In the following days Mrs Y displayed challenging behaviour towards staff and other residents.
• On 4 July Mrs Y told staff she had stomach pain and complained that she was unable to pass a bowel movement. Staff were advised to monitor.
• On 7 July Mrs Y had diarrhoea. Staff noted that she was upset and frightened. In the evening Mrs Y was agitated and hurt a staff member.
• From mid-July Mrs Y’s nutritional intake declined. On 16 July Mrs Y refused all foods but on 17 July staff noted an improvement in Mrs Y’s appetite, despite having an upset stomach and loose bowels. Staff asked to continue monitoring and to ‘push’ fluids.
• On 28 July a staff member noted, “ [Mrs Y] didn’t want supper, refused to eat anything… should really be on nutrition watch”.
• On 30 July the notes say, “[Mrs Y] has been a little down today and has needed emotional support from staff. She has not eaten or drank well despite encouragement from staff – please continue to push fluids and comfort when upset”. On 31 July a staff member noted, “didn’t want supper, refused to eat anything… should really be on nutrition watch”.
• Throughout early August Mrs Y continued to eat and drink very little and sometimes refused medication and personal care. Staff were reminded to provide encouragement with food and fluids.
• On 5 August Mrs Y was unhappy, soiled and had diarrhoea, but ate most of her food throughout the day.
• On 6 August Mrs Y ate very little and vomited at bedtime. Staff noted that her fluid intake throughout the day was low, and that Mrs Y would need encouragement to try different sources of fluid.
• On 7 August Mrs Y was not eating or drinking and vomited in the morning. In the evening a carer noted, “[Mrs Y] had faeces in her mouth this morning, senior [staff] has since cleaned it. Please observe as she hasn’t been herself today”
• On 8 August Mrs Y woke at approximately 1:30am. The notes reveal she was soiled, had blood on her bottom and then vomited. A few hours later, the notes say Mrs Y woke again and refused to go back to bed. She vomited bile. The carer noted that Mrs Y, “… had been eating her own phieses [sic] during the day and refused drink”. The carer said, “please monitor or call GP if situation continues or gets worse”.
• On 9 August Mrs Y received a visit from family members, who expressed concern about Mrs Y’s presentation and her withdrawn state.
• On 10 August Mrs Y continued to refuse food and fluids and was agitated, confused and sometimes aggressive. Mrs Y vomited twice in the morning. Due to concerns about the consistency and dark colour of the vomit, staff called the GP at 09.16 and received advice to call 999. An ambulance transferred Mrs Y to hospital at around 10:00.
19. Mrs Y’s care plan, which was produced at the time of her admission, noted Mrs Y had a ‘normal diet’ and ‘healthy appetite’. It said that Mrs Y ‘eats well’ and ‘enjoys healthy food and snacks’. However, the plan was later updated to say that “nutrition is cause for concern – consider monitoring dietary intake/weighing monthly”.
20. The care plan also noted that Mrs Y enjoyed the company of her family. Mrs Y’s son, Mr Y, was named as the nominated person to visit in the home. In line with the May 2021 government update, the plan said Mrs Y could see other nominated family members by pre-booked visits.

Was there fault by the care provider causing injustice to Mrs Y?

21. Mr Y says his family were shocked to witness the significant decline in Mrs Y when they visited in August 2021. Having read the records, this is not surprising; Mrs Y’s nutritional intake throughout July and early August had significantly declined and on several days Mrs Y ate virtually nothing. Mrs Y also regularly refused personal care and medication. Coupled with this, Mrs Y was showing signs of significant agitation, confusion and distress. Staff noted that Mrs Y would sometimes hit out and verbally abuse those around her. Mrs Y’s confusion escalated and on 7 and 8 August it is noted that Mrs Y consumed her own faeces.
22. When admitted to the home, the care plan said Mrs Y had a healthy appetite and there were no concerns about her nutritional intake. It is possible that the confusion caused by a change in her environment initially had an impact on Mrs Y’s appetite. However, the records show the decline in Mrs Y’s food and fluid intake continued throughout July and into August with some staff noting that she needed nutritional monitoring. This is echoed by the care plan which says the home should consider regular weighing. But I have seen no evidence of this.
23. Although daily records carefully detail the type and amount of food and fluids offered to Mrs Y, along with a record of how much she consumed, there is no monitoring of her weight or general decline. Despite the loss of appetite continuing over a prolonged period, there is no evidence to show the home escalated this or contacted relevant health professionals to discuss possible ways of improving Mrs Y’s intake, such as with a fortified diet. In my view, this is contrary to the requirements imposed by the fundamental standards of care and is fault.
24. Furthermore, when staff noted that Mrs Y was consuming her own faeces, there is no evidence showing how the home intended to overcome this issue to maintain both Mrs Y’s safety and dignity. I note that Mrs Y went to hospital three days after this incident, however there is no indication the home carried out any additional monitoring of Mrs Y in this interim period. In my view, this is also fault.
25. With the benefit of hindsight, we now know that Mrs Y had an untreated UTI which was likely adding to her lack of appetite and increased confusion. It is also relevant to note that Hertfordshire County Council investigated a safeguarding concern about Mrs Y’s experiences in the home. The Council upheld the concern because its investigation substantiated the claim of neglect and organisational abuse. The Council noted that Mrs Y received inadequate care and found evidence of significant systemic failures in the home.
26. Although we cannot say whether Mrs Y’s long-term prospects would have been any different, were it not for the fault identified, I consider Mr Y has experienced significant distress as a result of the home’s actions.
27. When someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of that impact whilst they were alive. This is because the person affected cannot benefit from such a payment. However, if we consider the person who has complained to us has been adversely affected by seeing the impact on their relative, we may recommend a symbolic payment to them as a remedy for their own distress.
28. I have also considered whether the home wrongly restricted the family’s visits. I have seen no evidence of this. To the contrary, Mrs Y’s care plan sets out the COVID-19 visiting arrangements. These were in accordance with the government guidance in place at the time.

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Agreed action

29. Within four weeks of our final decision, the care provider will provide evidence to show it has:
• apologised and made a symbolic payment of £700 to Mr Y for the distress caused by the failures identified in this statement.
30. Within eight weeks of our final decision, the care provider will also:
• share evidence with the LGSCO of the steps it has taken to remind staff about the importance of appropriately monitoring the weight and wellbeing of service users who experience a decline in their food and fluid intake.

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Final decision

31. We have completed our investigation with a finding of fault causing injustice for the reasons explained in this statement. The agreed actions are an appropriate remedy for the injustice caused.

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Investigator's decision on behalf of the Ombudsman