Summary: Mrs D complained about the care provided to her late father in St Mary’s Lodge care home. We found some of the care provider’s actions and gaps in record-keeping caused uncertainty to Mrs D. It has agreed to apologise and make a payment to her to remedy this.

The complaint

1. Mrs D complains that the care provided to her late father, Mr J, in St Mary’s Lodge care home from February to April 2022 fell short of standards, amounting to neglect and that care staff failed to pass on correct information to health professionals. This resulted in a sudden decline in his health and ultimately his death. Mrs D also complains there was poor record keeping and the Home did not reply to her concerns.

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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. 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)
3. We investigate complaints about councils and certain other bodies. We cannot investigate the actions of bodies such as the NHS. (Local Government Act 1974, sections 25 and 34A, as amended)
4. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by their personal representative (if they have one), or someone we consider to be suitable. (Local Government Act 1974, section 26A(2), as amended)
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)
6. 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

7. I spoke to Mrs D about her complaint and considered the care provider’s response to my enquiries.
8. 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

9. 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.
• 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.
10. 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

11. Mr J was in his eighties. He had dementia and did not have capacity to make decisions about his care. He lived at home with his wife, Mrs J, who cared for him. After Mrs J was injured following a fall the family decided to seek residential respite care for Mr J.
12. Mrs D contacted St Mary’s Lodge (“the Home”), which is a residential care home operated by Private Medicare (“the care provider”). Mr J moved into the Home in February 2022, initially for two weeks respite care.
13. On admission to the Home his care plans say Mr J needed help with toileting and personal care and his food cutting up. He was able to walk without a frame with two carers escorting him. The daily care notes show that Mr J sometimes became agitated.
14. On 22 February Mrs D agreed to extend Mr J’s stay at the Home as her mother was still recovering from her injury. Mrs D told me that as Mr J was due to return home his GP was not changed.
15. In early March, Mrs D’s sister found Mr J had not had continence care. He was also found sat on the floor following an unwitnessed fall. The Home has accepted it did not inform his family of this. The care notes show he was checked following the fall and was content.
16. A few days later the Home closed to visitors due to a norovirus outbreak. I have seen no evidence that Mr J contracted norovirus.
17. The daily care notes for the next two weeks give no indication of any concerns about Mr J’s health or wellbeing, apart from occasional incidents of agitation. His food diary and fluid charts show he was eating and drinking, though he ate very little on 16 March. Mr J was weighed and his MUST score was recorded as zero on 15 March. This means he was at low risk of malnutrition.
18. A primary care paramedic visited Mr J on 17 March. This not in the Home’s records but the GP’s record says Mr J was settled during the visit, slept during the day and could be agitated on waking. Mr J would “eat small amounts but needs a lot of encouragement ... unsteady on feet.”
19. The family visited on 18 March when the Home re-opened and raised concerns about Mr J’s pressure care as his skin was very red. Mrs D says that when family visited on 20 March, they found Mr J to be delirious, not speaking and possibly dehydrated. They asked the Home to contact the GP. The notes that day only record care given in the morning and after 8pm; there is no reference to the family’s concerns. The fluid charts say Mr J had had 500ml or less on 16, 19 and 20 March. The Home contacted the primary care paramedic but the paramedic or GP did not visit.
20. Mr J fell again on 24 March. The Home called 999 and he had to wait on the floor for several hours for the ambulance. The paramedics found there was no need for him to be admitted to hospital.
21. The GP visited the next day and requested a blood test. The GP’s record says Mr J “was sleeping; does not appear to be dehydrated; obs are normal.” Mr J fell three more times over the next few days, with ambulances being called and he was referred to the falls team.
22. Over the next month Mr J was seen 16 more times by various health professionals, including GPs and paramedics. There were also phone consultations with doctors and the 111 service. Mrs D and the family emailed the Home’s manager many times raising concerns about Mr J’s care.
23. The falls nurse saw Mr J on 29 March. She contacted the GP as Mr J was not taking his medicines. The practice advised they would not visit and Mr J should be seen by the GP practice which covered the Home’s area. Mr J was registered with the Home’s GP the next day.
24. The blood sample was taken on 30 March. There is reference to it not being possible to take the sample earlier due to Mr J’s agitation but it is unclear from the records when attempts were made. The blood test showed Mr J had an infection and antibiotics were started on 31 March.
25. Mrs D called 999 on 1 April as she was concerned that Mr J had deteriorated and was dehydrated. The primary care paramedic visited; she did not find Mr J to be dehydrated. There was an incident the next day where Mr J became agitated and “let his legs give way”. He stayed on the floor because carers felt it was unsafe to use an aid to assist him up as he was agitated. A continence referral was made.
26. The falls team doctor spoke to the Home on 4 April. The note says the Home advised that Mr J “was not dehydrated … takes his medicines fine … will walk independently.”
27. Mrs D made a safeguarding referral to the local authority as she was concerned about the care being provided. Mr J was seen by the Parkinson nurse and the GP on 6 April. The GP’s record says Mr J now needed help with eating, his mobility had worsened and “staff say he is hydrated”. The GP considered his deterioration may have been due to his dementia and parkinsonism. The fluid charts say Mr J had had 500ml or less on 28 March and 5 April.
28. When Mr J was weighed again on 7 April he had lost 9 kilograms and his MUST score was 2 (high risk). He was referred to the dietitian. Mr J stayed in bed from then on; there are some references to him being re-positioned to avoid pressure sores. He was discharged from the falls team and saw a physiotherapist. Mrs D contacted the GP as she pursued possible NHS funding for Mr J’s care; she felt Mr J was reaching the end of his life.
29. Mr J’s risk assessment for pressure sores was reviewed on 11 April and on 13 April the Home noted there were no known sores.
30. The local authority told Mrs D there was no further role for safeguarding as it considered the Home had taken appropriate steps to seek medical support and health professionals did not consider there were safeguarding concerns. Mr J’s deterioration was likely due to the progression of his dementia.
31. Mr J continued to lose weight; he had lost a further 3 kilograms by 19 April though his BMI was in the normal range; his MUST score remained high risk.
32. On 23 April an ambulance was called due to Mr J’s deterioration and problems breathing and swallowing. It was agreed with the paramedics he should remain in the Home. The next day, end of life medicines were provided. Whilst waiting for the district nurse to attend to administer them, Mrs D called 999 due to Mr J being in pain. Mr J went to hospital where he sadly died.
33. The Hospital records show he had an unstageable pressure sore. His cause of death was recorded as inanition, dementia and Parkinson’s disease. Mrs D made a safeguarding referral to the local authority. The Council told me its safeguarding enquiries are ongoing.

Mrs D’s complaint

34. Mrs D complained to the care provider on 23 May 2022. She said care had been inadequate, records were wrong, there had been days when the family witnessed a lack of food and fluids being given, and incorrect information had been given to health professionals. She also complained there had been a delay in Mr J being seen by the GP as the Home had wrongly considered he was not registered with his own GP. He had had no GP from 30 March to 5 April.
35. The care provider replied on 29 June that the Home had provided appropriate care and had sought medical attention when necessary. It apologised for not re-arranging a meeting Mrs D had requested. Mrs D remained dissatisfied and escalated her complaint.
36. The care provider’s final complaint response of 30 September accepted:
• there were gaps in its food and fluid records;
• it had no record of the primary care paramedic’s visit of 17 March;
• it had provided pressure area care but had not always recorded it, there were no records about Mr J’s pressure care from 21-25 April;
• there had been a delay in obtaining a blood sample; and
• it had not chased up the referral to the dietitian.
37. The care provider said it would carry out a lessons learnt exercise in relation to record-keeping. But it had found no evidence that carers had given false or misleading information about Mr J’s condition to health professionals.
38. It also said that during the norovirus outbreak families had not been told they could not visit but, in line with PHE guidance, had been made aware of the risks. In response to my enquiries, the care provider said it had offered “window” visits to families.
39. Mrs D came to the Ombudsman. She was concerned that neglect by the Home had led to Mr J’s deterioration and lack of nutrition and that care staff had not given health professionals a full picture of Mr J’s condition.

My findings

40. The Ombudsman cannot decide whether there has been criminal neglect, that is for the courts. My role is to consider if the actions of the care provider have caused injustice.
41. Having reviewed the daily care notes, I can see that the Home provided personal and continence care, offered food and fluids, gave Mr J his prescribed medications, checked him regularly and changed his position from 9 April.
42. When Mrs D requested a GP visit on 20 March, the Home contacted the primary care paramedic the next day but the GP did not visit until 25 March. I find the care provider should have chased up this visit and that not to do so was fault. Whilst paramedics came when Mr J fell on 24 March, it is likely the GP would have requested the blood test sooner if they had visited sooner. I cannot be sure that antibiotics would have been started sooner or that, if they had been, this would have prevented Mr J’s deterioration. But this uncertainty is an injustice to Mr J’s family.
43. There was another delay after the falls team nurse requested Mr J see a GP on 29 March. Mr J was registered with the new GP the next day but the GP did not visit until 6 April. I do not find that this delay was caused by fault by the Home but it was fault by the care provider not to chase up the visit. However, I note that in the meantime Mr J was seen by the primary care paramedic, the Parkinson’s nurse and the district nurse and there was a telephone review with the falls doctor. I therefore do not consider there would have been a different outcome if the GP had visited sooner.
44. The care provider has accepted there was a lack of records about Mr J’s pressure care. It appears Mr J was mobile until early April and there were no concerns about pressure sores. The risk assessment was reviewed on 11 April and there were no known sores at that time. Nonetheless, Mr J had a pressure sore on admission to hospital on 25 April. Whilst these may develop quickly when someone is reaching the end of their life, I find there was a failure to monitor or care for Mr J’s pressure areas from 11 April. This is fault and would have caused Mr J discomfort and pain. I cannot remedy that now as he has died.
45. The care provider has also accepted there were gaps in its records. I have noted in particular the pressure care, the paramedic’s visit on 17 March, Mrs D’s concerns about Mr J’s health on 20 March, and whether attempts were made to take blood samples. This is fault and a possible breach of Regulation 17. It has led to uncertainty about the care given to Mr J and exacerbated Mrs D’s mistrust of the Home.
46. Mrs D said the Home did not have valid deprivation of liberty authorisation in place. The local authority has sent evidence there was an application for an emergency seven day approval on 28 March. It is unclear whether there were approvals before or after that. I therefore find fault, but I do not consider it caused injustice as it is unlikely authorisation would have been refused or that Mr J would have been able to leave the Home.
47. Mr J lost a significant amount of weight and lack of nutrition was a key cause of his death. I have therefore considered very carefully whether the Home could have done more to encourage him to eat and drink.
48. The fluid charts show that Mr J drank 500ml or less on 21 days. He ate little, in particular from 7 March onwards, but he ate something every day until 23 April. The daily notes show that Mr J sometimes refused food and drink. 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 snacks.
49. Whilst the care provider has accepted there are some gaps and inaccuracies in its food records, a food diary and fluid charts were kept. I have seen no evidence that Mr J was not offered food or did not eat for long periods. Mr J was referred to the dietitian when his MUST score was high risk, which is in line with guidance. The dietitian had not visited before Mr J passed away, but this was not caused by fault by the care provider. Even if the referral had been chased, I could not say the dietitian would have visited sooner. Nor could I say what the outcome of that visit would have been.
50. Mrs D says the fluid records are fabricated as Mr J was able to only sip very small amounts. I have reviewed the charts and find they were completed contemporaneously, although the care provider has accepted there are gaps and inaccuracies. The charts say Mr J had more than 1200ml of fluid (the approximate recommended amount of six glasses) on 11 days. On 20 days after 5 March, they say Mr J drank 500ml or less. I do not consider the records show excessive or implausible amounts of fluid being given and I have no evidence of fabrication. Mrs D raised concerns about dehydration several times and this was considered by the GP and paramedic, but they did not find Mr J to be dehydrated.
51. Overall, I have seen no evidence that Mr J’s reduced appetite and refusal of food and drink was caused by fault by the care provider. The care provider took the actions we would expect in response to Mr J’s condition. I therefore do not find fault in relation to nutrition and hydration.
52. Mrs D says carers did not give health professionals a full and accurate picture of Mr J’s condition. As I was not there and have no independent third party account of the conversations, I can make no finding about what care staff told health professionals.
53. I have reviewed the Home’s notes and the medical notes of the discussions but I do not find significant discrepancies. The Home told the falls team doctor and the GP that Mr J was not dehydrated. This was a few days after the primary care paramedic had assessed Mr J as not being dehydrated. So, whilst I appreciate Mrs D’s concerns about the small amounts Mr J was drinking, I do not find these reports to be inaccurate.
54. Mr J was seen by health professionals 18 times in 38 days. They were therefore not solely reliant on care staff’s reports. Even if staff had advised that Mr J may be dehydrated, I cannot say whether the health professionals would have taken different actions.
55. Mrs D considered the care provider did not respond to her concerns. It has already apologised for not arranging a meeting with her to discuss those concerns, but it has provided a detailed response to Mrs D’s complaint. I do not find fault.
56. In summary, I find there was fault in:
• not chasing up the GP visits after 20 and 29 March, which has caused uncertainty to Mrs D and the family;
• pressure area care after 11 April, which caused injustice to Mr J; and
• record-keeping, which causes uncertainty.
57. 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.
58. Our guidance on remedies says that when we find evidence that the care someone received was so poor the fundamental standards may not have been met, a refund or waiving of some of the fees may be appropriate. I have found no evidence of substandard care, other than the incidents identified above. Our guidance says that for distress and uncertainty caused by fault, a symbolic payment of up to £300 may be appropriate.

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Agreed action

59. Within a month of my final decision, the care provider has agreed to apologise to Mrs D and pay her £300 to acknowledge the distress and uncertainty caused.
60. The care provider should provide us with evidence it has complied with the above actions.

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Final decision

61. 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