Summary: Mrs D complains that the care provided to her late mother, Mrs J, in Hutton Village Care Home, operated by Bupa, was inadequate. We found some of the care provider’s actions caused uncertainty to Mrs D and distress to her late mother. The care provider has agreed to apologise, make a payment to Mrs D and reduce the care fees to remedy this.

The complaint

1. Mrs D complains that the care provided to her late mother, Mrs J, in Hutton Village Care Home, operated by Bupa, between February and May 2022 was inadequate. In particular, that the Home did not ensure Mrs J had enough fluids, did not deal with her infections promptly and failed to act after she fell.
2. As a result, her mother’s condition deteriorated, she was hospitalised with dehydration and had falls caused by untreated UTIs. Mrs D says the poor care also caused significant distress to the family.
3. Mrs D also complains that there were errors in the charges made by the Home, causing her time and trouble.

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The Ombudsman’s role and powers

4. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
5. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)
6. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)
7. Under 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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How I considered this complaint

8. I spoke to Mrs D about her complaint and considered the care provider’s response to my enquiries.
9. Mrs D and the care provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Fundamental Standards of Care

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall. The standards include:
• Person-centred care (Regulation 9): The service user must have care or treatment that is tailored and meets their needs and preferences. Providers must involve a person acting on the service user’s behalf in the planning of their care and treatment.
• Dignity and respect (Regulation 10): Service users must be treated with dignity and respect and in a caring and compassionate way.
• Safe care and treatment (Regulation 12): Providers must do all that is reasonably practicable to mitigate risks to the service user’s health and safety. The provider must have arrangements to take appropriate action if there is a clinical or medical emergency.
• Food and drink (Regulation 14): Service users must have enough to eat and drink to keep them in good health while they receive care and treatment.
• Good governance (Regulation 17): Providers must maintain securely an accurate, complete and contemporaneous record in respect of each service user.
11. The Malnutrition Universal Screening Tool (MUST) identifies adults who are malnourished or at risk of malnutrition. It combines data about a person’s BMI and weight loss to produce an indicator of risk of malnutrition. A MUST score of 1 indicates medium risk, a MUST score of 2 or above indicates high risk. If a person is at high risk of malnutrition, they should normally be referred to a dietitian, weighed weekly and have high calorie snacks and fortified foods. Food and fluid intake should be monitored.

What happened

Mrs J’s care

12. Mrs J was in her nineties. She was deaf, had a high risk of falls and a history of urinary tract infections (UTIs) which caused confusion.
13. In February 2022 Mrs D contacted Hutton Village (“the Home”), which is a nursing home operated by Bupa (“the care provider”) and was quoted a price for Mrs J to stay there. Mrs J moved into the Home on 14 February after coming out of hospital.
14. The Home’s care plans say Mrs J could walk using a frame and with support from a carer, needed bed rails, and was on a normal, soft diet. The care provider has accepted there was no specific care plan in relation to her history of UTIs and confusion.
15. On 16 February the family noticed that Mrs J was confused. The nurse said she would inform the GP. The GP reviewed Mrs J on 18 February and prescribed antibiotics for a possible UTI. The next day Mrs J fell, causing bruising to her forehead. She was monitored and the falls care plan and risk assessment were updated but the care provider has accepted the GP did not review her.
16. Mrs J fell again two days later. The Home called paramedics who took her to hospital. Mrs J remained in hospital until 16 March. She had back pain caused by an old injury and was treated for the infection. The hospital prescribed a back brace.
17. Before Mrs J returned to the Home there was some confusion about whether she could be re-admitted with a back brace and whether she had dementia, which the Home did not make provision for.
18. On discharge to the Home, Mrs J had lost weight and had a high risk MUST score. She was referred to the dietitian by the GP the next day. There is a note that the kitchen was asked to provide fortified meals but the care provider has accepted that the subsequent records of what Mrs J ate and drank were not detailed, so it is unclear if these were given. I have seen no evidence that Mrs J was weighed every week. She remained in bed until she left the Home in May 2022.
19. Mrs D says on 18 March she found her mother in the bed wearing only a pad on her bottom half, in distress, shouting out and wedged at the side of the bed. The Home has apologised to Mrs D for this incident.
20. The GP reviewed Mrs J on 22 March. She continued to be confused and there is reference to her not eating much and not liking the texture of the food. Further antibiotics were started from 26 March. On 30 March it is noted that Mrs J was very sleepy and had missed breakfast; food and drinks were encouraged when she woke up.
21. The GP asked the Home to discuss with the family whether they thought Mrs J might have dementia. The family said the problem was the UTI, her deafness and that she needed fluids. The GP requested an urgent blood test and changed the antibiotics. The blood test showed Mrs J to be low on sodium but she did not need to go to hospital.
22. On 6 April it was noted Mrs J was sleepy and lethargic. Mrs J had again lost weight but the MUST score was not calculated. The dietitian assessed her and recommended nutritional shakes and a referral to the speech therapist. The nutrition care plan was updated to say Mrs J should have a pureed diet and fortified foods. It says “episodes of confusion impacting on her appetite and daily food intake.”
23. Following a further blood test, Mrs J’s sodium level was found to be extremely low and she went back to hospital on 11 April for treatment. After she returned on 21 April, she was very sleepy and confused. The GP referred her to the dementia clinic. There are notes that Mrs J was refusing food and drink due to her sleepiness. The GP prescribed nutritional shakes which were given from 30 April.
24. Mrs J’s condition deteriorated after 4 May as she continued to be very confused and sleepy. She was refusing food and fluid and had lost more weight by 7 May. On 10 May Mrs D says she found her mother’s fluid chart had not been completed; a nurse completed it in the evening. That night Mrs J had a nosebleed and vomited.
25. The GP visited on 12 May and found Mrs J was dehydrated. She went back to hospital the next day. Mrs J was discharged from hospital to another care home on 1 June. Mrs D says her mother then steadily improved, started to feed herself, read the papers and did not have another UTI. Mrs J sadly died a few months later.

Invoicing

26. The Home charged Mrs J for the whole period she was there. They applied a 10% discount for the times she was in hospital.
27. Mrs D says she was quoted an incorrect price, charged for a double room and was then told prices had gone up. The Home sent incorrect invoices without applying the hospital discount. These were later amended. She says she asked for a meeting to discuss the charges but this did not happen.
28. The care provider says Mrs D was initially wrongly quoted a price for respite care. It has apologised for the problems with invoicing.

Mrs D’s complaint

29. When collecting her mother’s belongings, Mrs D told staff at the Home that she would be making a complaint. The care provider sent a written response to this oral complaint on 21 June. Mrs D was dissatisfied as she had not yet put her concerns in writing. She complained formally to the care provider on 25 July.
30. In its responses the care provider apologised and accepted:
• Its record-keeping was not detailed enough, in particular in relation to Mrs J’s food and fluid intake.
• Staff had not acted in response to the possibility of a UTI on 16 February and there was no specific care plan about UTIs which could have said what signs to look for, what actions to take or how to help avoid them.
• The GP did not review Mrs J after she fell on 19 February and no actions were taken to reduce Mrs J’s risk of falls after the first one.
31. The care provider said it would give staff refresher training about care planning, record-keeping, signs of infection, actions to be taken after a fall, and the principles of person-centred care and dignity. Senior staff would check food and fluid charts.
32. Mrs D came to the Ombudsman. She said whilst the care provider had apologised, the problems should not have happened in the first place and she was concerned that others may be being affected by poor care.

My findings

33. Having reviewed Mrs J’s daily care notes, I can see that the Home provided personal and continence care, changed Mrs J’s position and applied creams to pressure areas, encouraged food and fluids, gave her prescribed medications and checked her regularly. Mrs J’s dignity may not have been maintained in the incident on 18 March, which is a possible breach of Regulation 10.
34. There was one incident of not dealing promptly with a possible UTI, which was on 16 February. However, antibiotics were started on 18 February so I do not find that Mrs J was caused a significant injustice and I cannot say that she would not have fallen if the antibiotics had been prescribed sooner. The records show that after that Mrs J was given antibiotics as prescribed. The infection did not appear to be clearing but this was not caused by fault by the care provider.
35. After Mrs J fell, the GP was not informed and the care provider says it took no further falls prevention action. However, the family were informed and the falls care plan and risk assessments were reviewed, in line with what we would expect. There were already bed rails and pressure mats in place, Mrs J was checked regularly and her UTI was being treated. On the evidence seen I do not find fault with the actions taken by the Home after Mrs J’s fall.
36. Mrs J did not have enough food or fluids as she was admitted to hospital with very low sodium levels on 11 April and with dehydration on 12 May. She also continued to lose weight.
37. I have considered very carefully whether the Home could have done more to encourage Mrs J to eat and drink. This is difficult as the care provider has accepted the records are not detailed enough, which is fault and a possible breach of Regulation 17.
38. However, the records do show that from 5 April Mrs J was sleepy and confused and often refused food and drink.
39. If a person refuses food, I expect the Home to keep records of food and fluid intake, inform the family, and refer to the GP and dietitian. Carers should continue to offer food and offer alternative snacks or foods with high nutrient value.
40. Mrs J had been referred to the dietitian, was on a soft, fortified diet and nutritional shakes were prescribed on 29 April. But the lack of records mean there is uncertainty about whether more could have been done, in particular in relation to how often she was encouraged to drink. This uncertainty is an injustice to Mrs D as she can never be sure whether her mother’s deterioration could have been prevented.
41. The CQC’s fundamental standards say care providers must follow people's consent wishes if they refuse nutrition and hydration, unless a best interests decision has been made under the Mental Capacity Act 2005. Despite Mrs J’s confusion and the GP’s query that she may have had dementia, I have seen no assessment of Mrs J’s mental capacity and therefore no best interest decision about her nutrition. Whilst I cannot say what the outcome of any capacity assessment or best interest decision would have been, I find it was fault not to consider this. This again causes uncertainty to Mrs D as she cannot know whether Mrs J’s dehydration and weight loss could have been prevented.

Remedying the injustice caused by fault

42. We cannot now remedy the injustice to Mrs J as she has passed away, but Mrs D and the family are left with the uncertainty and distress about whether Mrs J’s condition could have improved.
43. When we have evidence of fault causing injustice we will seek a remedy for that injustice which aims to put the complainant back in the position they would have been in if nothing had gone wrong. When this is not possible, we will normally consider asking for a symbolic payment to acknowledge the avoidable distress caused. But our remedies are not intended to be punitive and we do not award compensation in the way that a court might. For uncertainty caused by fault, the Ombudsman’s guidance on remedies recommends a symbolic payment of up to £300.
44. When the person affected has died, we will not normally seek a substantive remedy in the same way as we might for someone who is still living. This is because we would not expect a public or private body to make a payment that would enrich a person’s estate. However, if there is clear evidence of a quantifiable financial loss arising from the fault, we will normally recommend a financial remedy that repays that loss to the deceased person’s estate.
45. If we find evidence that the care received was so poor that the fundamental standards were not met, we consider the person did not receive the service either at all or to an acceptable standard and may recommend a full refund of care fees.
46. Whilst there were possible breaches of Regulations 10 and 17, I do not find evidence that the fundamental standards were not met. Nonetheless, some of the actions by the care provider have caused significant distress and injustice to Mrs D and Mrs J became dehydrated and needed to be hospitalised. I therefore consider the care she paid for fell below expected standards at times and it would be appropriate for the fees to be reduced by 10%.
47. The care provider has already apologised to Mrs D for the problems with invoicing. I consider that is an appropriate and proportionate remedy for the injustice caused to Mrs D.
48. The care provider has already given staff training so I make no further service improvement recommendations.

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Agreed action

49. Within a month of my final decision, the care provider has agreed to:
• apologise to Mrs D and pay her £300 to acknowledge the uncertainty she has been caused by poor record keeping.
• reimburse 10% of the fees to Mrs J’s estate. It should make the payment to Mrs D.
50. The care provider should provide us with evidence it has complied with the above actions.

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Final decision

51. There was fault by the care provider. The actions the care provider has agreed to take remedy the injustice caused. I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman