Summary: We have upheld a range of complaints about the late Mrs X’s care including about personal hygiene, record keeping, ensuring appropriate fluid intake and taking appropriate action when her health declined. The Care Provider has already taken some action to prevent recurrence, apologised and waived some fees. The Care Provider will complete further checks to ensure residents have tailored medication care plans and a check to ensure residents’ attorneys are correctly identified and recorded and that our contact details are given in final complaint responses.

The complaint

1. Mrs X complained about her late mother Mrs Y’s care in Charlton Court (the Care Home), one of Akari Care Limited’s (the Care Provider’s) care homes. She complained about:
1. A failure to record her (Mrs X’s) legal status which led to the Care Home not involving her in Mrs Y’s care
2. A failure to ensure Mrs Y had access to a call bell
3. Inappropriate use of sedation
4. Not supporting Mrs Y with personal hygiene
5. Failure to ensure she had adequate food and fluids
6. Inaccurate record keeping
7. Staff conduct
8. A failure to take appropriate action at the start of January 2022 when Mrs Y became unwell.
2. Mrs X said this caused her and Mrs Y avoidable distress.

Back to top

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. 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)

Back to top

How I considered this complaint

6. I considered the complaint to us, the Care Provider’s response to the complaint and documents described in this statement. I discussed the complaint with Mrs X.
7. Mrs X 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

Relevant law and guidance

8. Regulation 10 of the 2014 Regulations says people using care services should be treated with dignity and respect including ensuring privacy and autonomy.
9. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
10. Regulation 12(i) of the 2014 Regulations says a care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents.
11. Regulation 17 of the 2014 Regulations requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.
12. Regulation 14 of the 2014 Regulations says the nutrition and hydration needs of residents must be met. They must receive suitable nutritious food and fluid to sustain life and good health, with support to eat and drink if needed.
13. Regulation 12 of the 2014 Regulations says care must be provided in a safe way including assessing risks to the safety of people using the service and doing all that is reasonably practicable to mitigate risks. Where equipment or medicines are supplied the care provider should ensure there are sufficient supplies to meet needs and medicines are managed safely. Guidance explains medicines should be given accurately and in line with the prescriber’s instructions and at suitable times to ensure the person is not placed at risk.
14. NEWS (National Early Warning Score) is an NHS system to monitor patients whose health may be declining. The Care Provider has a policy about the use of clinical observation and NEWS scores. It says when there are signs a resident’s physical condition has changed, they have an infection or they are becoming unwell, trained staff will take clinical observations (temperature, oxygen levels. blood pressure, pulse, breathing and alertness) and record these with scores on a standard chart. If a person scores between one and four, then observations need to be repeated every six hours. If they score five or more, then observations should be repeated hourly and a score of seven or more needs a call to 999.

What happened

15. Mrs Y had dementia. She was frail, used a wheelchair and needed two carers to hoist her from bed to chair and back. Her health declined and she was admitted to hospital where she died in January 2022.

Mrs Y’s fluid and food records

16. The Care Home kept records of Mrs Y’s fluid intake. The charts had a standard ‘target intake’ of 2000ml a day. For the last two weeks of her life, Mrs Y never achieved this target. The most she had was 1430. Her typical fluid intake was around 1000 ml. The last three days were 670, 200 and 100 ml respectively.
17. The Care Home also recorded Mrs Y’s food intake. I have looked at the records for the last two weeks of Mrs Y’s stay at the Care Home. She had a varied diet of traditional English food including pies, pasties, sandwiches, toast and a Sunday dinner for the first week to 10 days. For the last few days, Mrs Y was sleeping in the day and often missed breakfast and lunch. Her food intake was poor for the last few days before admission to hospital.

Mrs Y’s daily care notes

18. I have summarised the daily care records kept by care staff for the last week of Mrs Y’s stay.
19. On the afternoon of 29 December 2021, Mrs Y was noted to be confused, wheezy and breathless. Staff called an ambulance. Paramedics assessed Mrs Y’s breathing and spoke to her GP. The paramedics and the GP decided not to take Mrs Y to hospital and the plan was the GP would review her on 4 January. The paramedics advised care staff to monitor Mrs Y and to call 111 if she declined. She ate most of her food in the afternoon.
20. On 30 December, Mrs Y was vocal in the night. There were no concerns about her breathing. She was settled in the day and had a sedative.
21. On 31 December, Mrs Y fluctuated in mood, she had a fair diet and fluids. She was noted to be tearful and shouting, was given a sedative and settled.
22. On 1 January, Mrs Y was anxious and agitated. She had a sedative and settled.
23. On 2 January, Mrs Y was noted to scream now and again.
24. On 3 January, Mrs Y was awake some of the night, she had a lot of reassurance and slept after 03:00. She was too sleepy to eat at lunch and was recorded as being asleep at 16:30. The records said her diet that day was poor because of her sleeping a lot. She had tea and toast at 22:00. She slept well that night.
25. On 4 January, Mrs Y’s mental health nurse phoned the Care Home following a referral from the GP. The mental health nurse recommended an increase to one of Mrs Y’s regular medicines and asked staff to monitor Mrs Y’s behaviour for four weeks. Mrs Y remained in bed all day. She was unsettled and had a sedative. There is no record of the GP reviewing Mrs Y.
26. On 5 January, Mrs Y slept most of the day. She had half a yoghurt and 50 ml water at 17.49. The records say at 18:46, the nurse completed a NEWS score and called 999. The Care Provider said in the complaint response that the NEWS score had been completed earlier at 17:00 and uploaded to the system at the later time (18.46)
27. Mrs X obtained the ambulance service’s recording of the nurse’s call to 999. I have listened to the recording. The nurse confirmed Mrs Y was not conscious, her breathing was wheezy and told the operator Mrs Y was prone to chest infections. The nurse gave the operator Mrs Y’s vital signs (temperature, oxygen levels and blood pressure) when prompted and confirmed there were cases of COVID-19 in the home.
28. The nurse said in a statement for this investigation:
• Mrs Y’s condition had been deteriorating over the past two months. The GP and mental health team had increased her medication as she was often distressed. She had taken a sedative for the past few mornings before she was taken to hospital
• She had been sleeping a lot in the day and didn’t wake up till tea-time.
• On 5 January, Mrs Y’s oral intake was poor, she was settled after a sedative. The nurse said she did not have any symptoms and staff who were on shift knew Mrs Y well and did not report any concerns or a change in presentation from how she had been. Mrs Y was not rousable and so she (the nurse) completed a NEWS score and called 999 straight away.

The Care Provider’s responses to the complaint

29. The Care Provider upheld most of Mrs X’s complaints. I have summarised the responses below:
1. It accepted the Care Home did not record the POA status of family members accurately and this meant they were not consulted about care plans. The administrator has since audited the documents of all residents to check their relatives’ legal status is properly recorded.
2. It cannot evidence Mrs Y had easy access to the call bell. The electronic case records (called ‘Nourish’) has a facility to record when a call bell is not plugged in. The Care Provider said it would get the system updated so it was a compulsory action for staff to record the call bell when they filled in the records. The manager had already spoken to staff to tell them to make sure call bells were plugged in and within reach
3. Action was taken against a staff member about the administration of sedatives. There were occasions when it was not clear why these were administered. The manager was leading a regular clinical meeting with nurses and competency of staff would be checked. The manager was also auditing medication and the Clinical Commissioning Group had visited to do similar checks
4. It was sorry there were occasions family had to complete personal care. The lack of care recorded for Mrs Y fell short of expected standards. The Chief Operating Officer was starting a review to ensure all residents were being supported to bath and/or shower in line with their preferences
5. The Care Provider did not set a standard target for fluid intake. There were occasions when Mrs Y had less fluid than needed
6. It accepted records fell short of accepted standards and this eroded the family’s confidence. When a record didn’t describe care delivery, it was reasonable to conclude care was not delivered. Staff completed records after the event and Nourish recorded the time of the entry rather than when care was actually delivered. The manager had told staff to complete records at the time where possible and if not, to state the actual time of care
7. It was sorry for a staff member’s conduct. It could not give more details about action taken.
30. The Care Provider also wrote to the Care Quality commission. The letter repeated much of the information in the previous paragraph. It also clarified:
1. The decision for Mrs Y to remain in the Care Home on 29 December was made by the paramedic and GP without input from the family
2. The actions of staff on 5 January were not recorded contemporaneously. The nurse described she completed the NEWS chart at 17:00 and uploaded it at 18.46. The timing of the 999 call was not recorded, nor was the time when the ambulance arrived and left. Feedback would be given to relevant staff.
31. The Care Provider offered Mrs X a refund of fees of £3400 in a later letter and apologized. None of the complaint correspondence signposted Mrs X to the LGSCO.

The Care Provider’s actions since upholding the complaint

32. I asked the Care Provider for documentary evidence of the actions it said it would take to improve the service after Mrs X’s complaint. I have summarised the evidence of action taken below:
1. The Care Home’s manager completes monthly unannounced visits to the Care Home in the middle of the night, early in the morning, at weekends and at bank holidays. The manager also conducts weekly walkabout checks during the day. The manager checks call bells, cleaning, records, PPE and the environment as well as care delivery. I have seen monthly written reports evidencing unannounced out of hours visits as well as weekly checks.
2. The local authority’s commissioning team visited the Care Home for quality monitoring. The report made some recommendations about more detailed completion of care records.
3. The manager completed clinical supervision of the nurses in May 2022. I have seen the notes of those meetings. Refresher training in administering medication was to be completed shortly. The manager discussed Mrs X’s complaint with nurses.
4. Nurses and/or the manager complete a monthly medication audit considering supply, storage, record keeping and administration. A written report with required actions is kept and read by the manager.

Findings

Complaint (a): there was a failure to record Mrs X’s legal status which led to the Care Home not involving her in Mrs Y’s care

33. The Care Provider upheld this complaint. The failure to record Mrs X as Mrs Y’s power of attorney was not in line with Regulation 17 because the records were not accurate. This meant Mrs X was not properly involved in Mrs Y’s care. This caused avoidable confusion and distress.

Complaint (b): there was a failure to ensure Mrs X had access to a call bell

34. The Care Provider upheld this complaint. This was fault which meant care was not in line with Regulation 9 of the 2014 Regulations. It would have caused Mrs Y avoidable distress not to be able to call for help when needed.

Complaint (c): there was inappropriate use of sedation

35. The Care Provider’s own investigation found a lack of clarity about why sedation was administered. Care was not in line with Regulation 12 and this was fault. The lack of guidelines for the use of sedation means the Care Provider cannot evidence the medicine was used appropriately or in a way that did not place Mrs Y at risk.

Complaint (d): staff did not support Mrs Y with personal hygiene

36. The Care Provider upheld this complaint. This was fault. The Care Provider has not evidenced care in line with Regulation 10. This caused Mrs Y a loss of dignity.

Complaint (e): there was a failure to ensure Mrs Y had adequate food and fluids

37. The Care Provider said in its complaint response that there was no target of 2000ml of fluids for Mrs Y. Yet her records said the opposite. The Care Provider’s care was not in line with Regulation 14. The standard ‘target’ intake of 2000 ml (which was said not to be a target) caused confusion about how much Mrs Y needed to drink to maintain good hydration. The Care Provider should have liaised with Mrs Y’s GP for advice about hydration. There is no evidence it did so which is a failure to act in line with Regulation 12 and fault.
38. Mrs Y’s food intake records indicate a varied diet and there is no evidence of fault. Her intake declined when she became ill but this was to be expected and was not fault.

Complaint (f): inaccurate record keeping

39. The Care Provider upheld a complaint about the accuracy of records. It was required by Regulation 17 to keep accurate, complete and contemporaneous records of care delivered. It did not do so and so was at fault. I do not consider this caused specific injustice.

Complaint (g): Staff conduct

40. The Care Provider upheld this complaint and apologised. This is an appropriate response.

Complaint (h): there was a failure to take appropriate action at the start of January 2022 when Mrs Y became unwell.

41. Mrs Y’s decline in health may not have been clear to staff. She was sleeping a lot in the day, having received a sedative most days which appears to have been administered because of observed signs of distress or agitation like screaming. So any underlying decline in her physical health may not have been apparent. I note the paramedics attended on 29 December and decided not to admit her. The decision to admit or otherwise was not the Care Provider’s decision, it was for the GP and paramedics.
42. The GP was supposed to review Mrs Y on 4 January. However, a GP review did not take place. It is not clear why there was no GP review; the records indicate the GP instead referred Mrs Y to an NHS mental health nurse. The mental health nurse did not review Mrs Y in person, only spoke with care staff and instructed them to increase the medication used to stabilise her behaviour. On 4 January, Mrs Y’s food and fluid intake was low, she was sleeping a lot and had required sedation to settle her. My view is the Care Home should have asked the GP to see Mrs Y as was originally intended. I say this because of Mrs Y’s reduced food and fluid intake, sleepiness and agitation which were potential indicators of a decline in her physical health. I cannot say on a balance of probability that the outcome would have been an earlier admission to hospital, had the GP seen Mrs Y on 4 January, but Mrs X is left with the uncertainty that the outcome may have been different.

Back to top

Agreed action

43. I am satisfied with the actions the Care Provider has taken action to improve the service for others and to minimise the chance of recurrence. I have summarised action taken in paragraphs 29 and 30. However, there are some additional actions it has agreed to take following this investigation which will further minimise the risk of similar fault and injustice occurring.
44. The Care Provider will within one month:
• Complete a further audit of all current residents’ records to check that it has up to date information about whether or not the resident has a POA and if so, the POA’s contact details
• Complete an audit of care plans for residents receiving medication on an ‘as and when required’ basis to ensure there is a tailored care plan with guidelines for usage in each case
• Remind all staff responsible for signing off final complaint responses that letters need to give full contact details for the LGSCO as the next stage in the complaint procedure.
45. The Care Provider should provide us with evidence it has complied with the above actions.
46. Mrs X seeks a full refund for all the fees paid for the late Mrs Y’s care. This is not in line with our published Guidance on Remedies where the person affected has died and so I have not recommended it. The Care Provider has already apologised and agreed a reduction of £3400 in the fees. This is an appropriate remedy to reflect any distress to Mrs X.

Back to top

Final decision

47. We have upheld a range of complaints about the late Mrs X’s care including about personal hygiene, record keeping, ensuring appropriate fluid intake and taking appropriate action when her health declined. The Care Provider has already taken some action to prevent recurrence, apologised and waived some fees. The Care Provider has accepted our recommendation to complete further checks to ensure residents have tailored medication care plans and a check to ensure residents’ attorneys are correctly identified and recorded and that our contact details are given in final complaint responses.
48. I have completed the investigation. 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

Investigator's decision on behalf of the Ombudsman