Summary: Mrs X complained about the care provided to Mr Y during his short stay at The Links. Mrs X says the Care Provider did not keep Mr Y safe and did not meet his care needs as agreed. We find the Care Provider at fault in the way it cared for Mr Y, and this caused Mr Y, Mrs Y and Mrs X injustice. We recommended the Care Provider reimburse the full cost of his stay and pay Mrs Y £500, and Mrs X £200. It should also provide an action plan showing progress on the actions it identified to avoid similar faults in future. It has agreed to complete these actions.

The complaint

1. Mrs X complained about Mr Y’s short stay at The Links, run by BUPA Care Homes (PT Links) Limited (the Care Provider). She says the Care Provider:
• Failed to keep Mr Y safe; he left the home without staff being aware;
• Failed to inform the family that he had left the home; they found out from the Police;
• Neglected Mr Y’s personal care;
• Failed to properly administer Mr Y’s diabetes treatment and test his blood sugar levels;
• Failed to keep correct records; and
• Failed to keep the family informed through phone and email contact and providing records.
2. Mrs X says Mr Y leaving the home, and the neglect of his personal care and diabetic needs, caused the family, especially Mrs Y, distress. The Care Provider also caused her time and trouble in pursuing her complaint. She is also concerned about the risk to other vulnerable people. Mrs X would like a full refund of the £2000 care fee and is unhappy that the Care Provider has only offered a 50% refund.

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The Ombudsman’s role and powers

3. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. 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. 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). We consider Mrs X is a suitable person to complain on Mr Y’s behalf.

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. Mrs X and the Care Provider had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Background

Fundamental Standards of Care

8. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.

CQC

9. The Care Quality Commission (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.
10. Regulation 9 is about personalised care. The CQC’s guidance on the regulations says: “Providers must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate, meets their needs and reflects their personal preferences, whatever they might be”.
11. Regulation 12 is about safe care and treatment. CQC’s guidance says: “Providers must do all that is reasonably practicable to mitigate risks. They should follow good practice guidance and must adopt control measures to make sure the risk is as low as is reasonably possible. They should review methods and measures and amended them to address changing practice.”.
12. Regulation 17 is about good governance. 17(2)(c) says care providers should “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided”.

Safeguarding

13. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

What happened

14. Mr Y had dementia and diabetes. He went to stay at The Links for 10 days’ respite in Spring 2022, to give Mrs Y a rest. Mr Y’s preadmission assessment was completed over the phone with Mrs X. Due to an outbreak of COVID19, she was unable to visit the home. It noted his understanding of risk was “Fair” and that he was not at risk of absconding; he had “never wandered from home”. It also noted he had a history of confusion, memory problems, disorientation and hallucinations and he needed a sensor mat and hourly checks. Mr Y was also noted to lack the capacity to make the decision to move into the care home. The form notes that a Deprivation of Liberty Safeguards (DoLS) application should be made. He was graded as having “band 2” care needs – stable and predictable, low care needs with no greater than three hours of carer input needed each day. This included the expectation of additional measures eg DoLS, additional activities and additional staff training. Mr Y was usually continent but wore continence pants for security.
15. Mr Y’s insulin regime was noted on the preadmission assessment. It said he needed insulin four times daily:
• Breakfast 7 units into stomach
• Lunch 7 units into stomach
• Tea 12-15 units into stomach
• Night time 18 units into bottom

It noted his normal blood sugar level range was 12-15 mmols/l but could be 21 when he would need more units of insulin. Mr Y’s blood monitoring sensor did not need changing during his stay and was to check his levels before deciding the correct insulin dosage. It also noted that he could have “sandwich and pudding” for tea but would choose the wrong things if given a chance and it would affect his blood sugar levels.

16. On the first day of his stay, when Mr Y entered the home, the manager offered Mr Y a cup of tea and asked if he wanted sugar. Mr Y’s son, Mr Z, who had taken him in, reminded the manager that Mr Y was diabetic. Later the same day, Mr Y was given a “very sweet desert in error”. This raised his blood sugar levels to 25.9 mmols/l. The Care Provider spoke to Mrs Y who advised on appropriate action. Mrs Y advised that Mr Y only had a small desert at home and did not have cakes or biscuits. The following day the Care Provider spoke to Mr Y’s GP about the insulin dosage. However, the GP referred them back to Mrs Y who, they said, had managed Mr Y’s diabetes well for a long time.
17. Three days later, Mr Z visited and found Mr Y smelt strongly of urine. Mr Z alerted the Care Provider to this as it was unusual for Mr Y to be incontinent. The manager was unaware that Mr Y went to the toilet independently although this was detailed on the preadmission assessment and Mrs X had provided written details of Mr Y’s needs in his suitcase. Later, at 10:15pm, the Police phoned Mrs Y to say Mr Y had been found by a member of the public and was safe. Neither Mrs Y, nor her family, were aware he had been missing. The Care Provider did not telephone Mrs Y or any other member of the family until the following day at midday.
18. The Care Provider advised that Mr Y had been moved to a different, more secure floor, which was where Mrs X had understood he would be placed from the start. The Care Provider also found Mr Y had a urine infection and arranged for antibiotics. It updated Mr Z about this. It also investigated the incident under safeguarding procedures and took urgent action to fit a secure lock to the door through which Mr Y had left the home. Mrs Y complained that the Care Provider’s records state that staff left him in his room at 21:40 on the day he left the home. However, Police logged the call from the person who found Mr Y at 21:43 which meant the Care Provider’s records were inaccurate.
19. The following week, an agency nurse called 111 because they could only find 10 units of insulin in stock so could not give the 18 units needed. The out of hours service did not call back as advised, so Mr Y only had 10 units. The Care Provider said it monitored Mr Y’s blood sugar levels. The insulin was later found in the medication fridge on the ground floor.
20. Four days later, the Care Provider telephoned Mr Z because Mr Y’s night time insulin was running out. Mrs Y was worried by this because she had packed double the amount he needed. Mrs X telephoned and asked the Care Provider to check the medication fridge and it found the insulin was there.
21. The following day, Mr Y returned home. Mr Z said he looked as if he had not shaved since the previous week, he smelled of urine, and was wearing someone else’s trousers. He did not have his continence pants on and seven of the twelve pairs he had taken to The Links, were still in the packet. His blood sugar levels were high and the Care Provider had not advised whether it had given him his insulin after lunch although its records show it had given this. Mrs X checked Mr Y’s glucose scanning machine for the readings throughout his stay and only four days showed four tests or more. Each day should have at least four; one before each dose of insulin. On one day, there had been no checks, twice there were only two checks, and three times only three checks. On the day when Mr Y was given only 10 units of insulin when it should have been 18, it only showed three checks although it should have increased monitoring. There were only one or two checks (it is unclear) on the day Mr Y started antibiotics and Mrs X says checks should have increased because this can affect blood sugar levels.
22. The Care Provider has 36 blood sugar level tests recorded. This is four short of the minimum 40 that would mean Mr Y’s blood sugar level was checked before each dose of insulin. 19 of the 36 tests recorded, show a result within Mr Y’s normal range. On 8 occasions, the reading is higher than the 21 given by Mrs X as a high reading, which meant he would need more insulin. These are mostly during the first few days of Mr Y’s stay. On the day before he left the home, the reading was 26 and staff noted that Mr Y had eaten biscuits. The Care Provider’s medication record is not always clear about the number of insulin units given and is not always signed.
23. Mrs X complained to the Care Provider at the beginning of May 2022. It acknowledged her complaint the following day and said it would investigate and respond within 20 working days. Almost three weeks later, it wrote apologising that it had not yet responded and that it was still investigating. Just over a week after the original 20 working days had passed, Mrs X wrote to the Care Provider asking when it would respond. The Care Provider responded the same day and said a response was due by 21 June and apologised for the delay. The Care Provider wrote again and said although the investigation was now complete, it needed more time to prepare its response. It said it would respond by 27 June, however, the response arrived on 22 June.
24. Mrs X was not happy with the response and the Care Provider responded further in mid August. It said it recognised that it did not meet its usual high standards and recognised this had caused Mr Y and his family significant distress. It offered a £1,000 refund.
25. With regards to the management of Mr Y’s diabetes, the Care Provider said the manager would have given him sweetener not sugar when she asked on his arrival. It says in future it will document whether someone takes sugar or sweetener during the assessment. It also says some nurses preferred to use another, non-invasive method of monitoring blood sugar levels, not Mr Y’s scanner. It says it would not use an unnecessarily invasive procedure. This explains the number of checks showing on Mr Y’s scanner. It said it had discussed this with Mrs X as staff had not previously used the system Mr Y had. It said Mrs X said she did not have a problem with staff using the other method.
26. The Care Provider said Mr Y was “on occasions”, resistant to help with personal hygiene. It apologised that staff had not recorded the techniques they had used to encourage him. It said “staff would offer a choice in how his care was delivered or return to see whether he had changed his mind” later in the day. However, there is no evidence to support this.
27. With respect to records on the day Mr Y left the home unescorted, the Care Provider says a blood sugar check was done at 21:15. Insulin would have been administered shortly after so the time may be 10 – 15 minutes out. The Care Provider said staff said that in an emergency situation you don’t always look at the clock to see the exact time. However, when the entry was made, Mr Y was not missing so there was no emergency.
28. In relation to the medication records, the Care Provider said “staff advise it had been administered” on one occasion when the medication record was not signed.
29. The care Mr Y received fell significantly below the standard which he was entitled to expect. Instead of keeping him safe and giving Mrs Y a rest, it put him at an increased risk of harm and created significant undue stress and anxiety for Mrs Y and Mrs X. From the first day, the Care Provider failed to demonstrate that it understood Mr Y’s needs and did not adequately follow the agreed plan. This is a potential breach of regulations 9 and 17. Mr Y did not come to significant harm during his stay, but this was only by good fortune. It was only three days into his stay when he left the home unnoticed and fortunately came across a kind member of the public who kept him safe. The Care Provider should have alerted the family to this sooner.
30. The Care Provider has recognised that its records are not able to evidence the care it says it provided. It is not enough to say that staff say medication was administered, or that staff say they encouraged Mr Y with personal care. Records should provide the evidence that this happened. This is a potential breach of regulations 9, and 17. Mrs Y is now left with a lack of confidence in respite care and says she will never let Mr Y go back. This leaves an ongoing injustice in that she will never feel comfortable with what she will see as the risk of Mr Y going into respite care again.
31. I have identified potential breaches of regulations 9, 12 and 17, so I will send a copy of my final decision to CQC.

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Agreed action

32. To remedy the injustice identified above, I recommended the Care Provider:
• Provide another apology in writing. This should not apologise for what Mrs X ‘feels’ but for the faults identified above. It should also set out the actions it will take or has taken to avoid similar problems in future.
• Reimburse Mr Y with the full cost of his stay.
• Pay Mrs Y £500 to recognise the stress and anxiety it caused her.
• Pay Mrs X £200 to recognise the stress and anxiety it caused her.
• Provide an action plan showing progress on the actions it has identified to avoid similar problems in future.
33. The Care Provider agreed to these actions and should provide us with evidence it has complied with the above actions within one month.

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Final decision

34. I have completed my investigation and uphold Mrs X’s complaint.

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Investigator's decision on behalf of the Ombudsman