Summary: Mrs D complains on behalf of her late mother that there was inadequate care at Stambridge Meadows Care Home, operated by Larchwood Care. We found that some of the care provider’s actions caused injustice to Mrs D. The care provider has agreed to apologise and pay Mrs D £200 and provide training to staff on record-keeping.

The complaint

1. Mrs D complains on behalf of her late mother, Mrs F, that there was inadequate care from June to August 2022 at Stambridge Meadows Care Home, operated by Larchwood Care. In particular, that there was:
1. A lack of basic care and staff were not proactive in responding to her parents’ needs.
2. Poor personal and continence care.
3. Poor pressure area care.
4. Rough handling and failure to use the correct equipment when moving Mrs F.
5. Failure to seek medical or nursing advice promptly or to act on it.
6. Lack of support for eating and drinking, leading to weight loss and dehydration.
7. Poor record keeping.
8. Poor communication between staff and with the family.
9. Lack of training for staff.
10. Lack of staffing.
11. Lack of cleanliness and poor hygiene.
2. Mrs D says this caused a drastic decline in her mother’s health and mental well-being, as she developed infections, pressure sores, was in pain and her mobility deteriorated. It also caused distress to the family.

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The Ombudsman’s role and powers

3. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. We may investigate complaints from the person affected by the complaint issues, or from someone they authorise in writing to act for them. If the person affected cannot give their authority, we may investigate a complaint from a person we consider to be a suitable representative. (section 26A or 34C, Local Government Act 1974)
6. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
7. 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)
8. 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

9. I spoke to Mrs D about her complaint and considered the information she sent and the care provider’s response to my enquiries.
10. 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

11. 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.
• Premises and equipment (Regulation 15): Providers must make sure that the premises where care and treatment are delivered are clean, suitable for the intended purpose, maintained and where required, appropriately located.
• Good governance (Regulation 17): Providers must maintain securely an accurate, complete and contemporaneous record in respect of each service user.

What happened

12. Mrs F was in her 80s and had dementia. In June 2022 she and her husband went to stay in Stambridge Meadows Care Home (“the Home”), operated by Larchwood Care (“the care provider”).
13. Her care plan says Mrs F was on a normal diet but needed encouragement to eat. On 28 June, whilst family were visiting, Mrs D says her parents were left alone and food was left on a hard-to-reach table. The daily care notes for that day say Mrs F declined to eat breakfast and dinner and ate half her lunch. The daily notes for the next few weeks record no concerns about Mrs F.
14. On 18 July, the family called an ambulance as they were concerned about Mrs F’s health. She went to hospital and was prescribed antibiotics and a cream for a urinary tract infection. I have seen no reference to this incident in the Home’s records.
15. The prescribed cream was to be applied by a district nurse but is not listed in Mrs F’s medication chart and there is no evidence it was administered. In response to Mrs D’s complaint, the care provider said the district nurses had not been advised about it by either the hospital or the GP.
16. On 19 July the notes say Mrs F was complaining of “terrible back pain; has barely opened her eyes”. She was agitated and declined to eat. There is no record that this was referred to a nurse or GP. Mrs D says on 21 July her mother was left on her own with pain in her left hand, but this is not mentioned in the daily notes. Mrs D says the Home said it would ask the nurse to check Mrs F but this did not happen.
17. From 21 July onwards the records show Mrs F only drinking very small amounts and declining to drink.
18. A mental capacity assessment was carried out; this found Mrs F did not have capacity to make decisions about her care, although she could communicate her views.
19. Mrs F’s care plans were updated on 25 July. They said she was at very high risk of pressures sores, so a duo turn cushion on a static chair should be used. Mrs F was able to re-position herself in bed. The plans also say Mrs F sometimes refused personal care and was doubly incontinent, though Mrs D says her mother was always able to say if she needed to use the toilet. In relation to mobility, the care plan says whilst Mrs F was able to transfer from chair to bed with the help of two staff, this was variable and a stand aid was sometimes needed.
20. A paramedic practitioner checked Mrs F’s hand on 29 July and referred her for an X ray. No fracture was found; antibiotics were prescribed and a splint applied for support.
21. On 1 August Mrs F had lost 1.1kg in weight in four weeks but was not at high risk of malnutrition. A fluid chart was started. The next day she was in too much pain to get up and declined care and food. Mrs D met the Home to discuss concerns she had about Mrs F’s care, including about pressure sores.
22. The district nurse visited the next day. The notes says she found “two small dry skin patches; skin slightly excoriated due to using nappy rash cream.” A barrier cream was prescribed and the nurse was to review in a week.
23. Mrs F continued to decline food and drink, was in pain and lethargic. The GP visited on 4 August. He found her observations were normal and she was clinically stable. He said if the family was concerned, they could take her to A&E which may provide intravenous fluids.
24. The family called an ambulance the next day. The paramedics took Mrs F to hospital as they could not rule out dehydration. Mrs F’s infection was found to have doubled. Mrs F’s health records say she had two “category two” pressure sores.
25. Mrs D says on 6 August there was an incident of poor handling, where carers stood Mrs F up to provide personal care and transfer her to a chair. Mrs D was crying out in pain, the zimmer frame slipped, Mrs F started to fall and Mrs D had to hold her up.
26. The district nurse visited the next day. She checked Mrs F’s pressure areas. Her notes say “Pressure ulcers to sacrum improved. Left dressings off and advised care staff to cleanse with soap and water and apply barrier cream. Advised to start a turning regime.” She also reviewed Mrs F’s moving and handling care plan and reminded staff that the “wheelchair should be used for transfer only and Mrs F should not be sat in a wheelchair for any period of time.” The care plan was updated to say “if Mrs F can’t stand then staff are to use the hoist as advised by the district nurse and only to get her up for her meals.”
27. Mrs D says the nurse clearly specified that Mrs F should only be moved with a hoist and that the “if she can’t stand” was wrongly inserted by the care provider.
28. Mrs F moved to a new care home on 8 August. Mrs D says that morning she was lifted by her arms, rather than a hoist, and had been left in a wheelchair rather than in bed. Mrs F sadly died in October 2022.

Mrs D’s complaint

29. Mrs D complained on 13 August. The care provider responded on 27 October, following some discussion with Mrs D about whether to meet. It apologised that Mrs F’s experience at the Home had not been a positive one. It said:
• Cleanliness – a commode had not been cleaned and there were some gaps in the cleaning records. The manager would check room cleanliness.
• Personal care – there were some gaps in the records which would now be audited daily.
• Pressure care – Mrs F’s care plan and advice from nurses had been followed.
• Medication – the prescribed cream had not been applied as the district nurses had not been advised of it.
• Health – the paramedic had checked Mrs F’s hand on 29 July when family had raised concerns.
• Eating and drinking – staff had assisted Mrs F to eat and drink.
• Moving and handling – staff had been put on refresher training for moving and handling, but Mrs F’s care plan said to use a hoist if she could not stand and to use a duo cushion on a static chair.
30. On coming to the Ombudsman, Mrs D sent photographs showing possible thrush on Mrs F’s tongue, sore toes, dirty fingernails and being propped up with cushions as she was unable to support herself.

My findings

31. Having reviewed the daily care notes, I can see that the Home provided personal and continence care, offered food and fluids, gave Mrs F her medications, and checked her regularly.
32. However the care provider has accepted there were some gaps in its records, which is a possible breach of Regulation 17. In particular there were gaps in relation to the pain she had in her back and left hand, contact with health professionals and personal care. This causes uncertainty to Mrs D and the family about whether their mother was provided with the care she needed.
33. The daily note of 19 July say Mrs F was in pain, but there is no record of this being referred to a nurse or GP. Mrs D says pain was mentioned again on 21 July. On balance, therefore, I find the Home should have referred Mrs F to a medical professional sooner than 29 July, which is a possible breach of Regulation 12. Not to have done so caused her pain and distress for longer than necessary, but I cannot remedy this now as she has died.
34. The handling incident of 6 August was a possible breach of Mrs F’s dignity (Regulation 10) which again was not recorded.
35. I do not find evidence of fault in the use Mrs F’s use of the wheelchair prior to 7 August. On 7 August, the nurse advised Mrs F should stay in bed rather than a wheelchair and I do not dispute Mrs D’s account of what happened on 8 August. But Mrs F’s care plan was to use a static chair with a duo cushion and I have seen no evidence Mrs F’s care plan was not followed before 7 August.
36. In relation to the use of a hoist, there is a dispute about whether the district nurse advised from 7 August Mrs F should always be transferred with a hoist, or only if she could not stand herself. This is again fault in record-keeping and I cannot now remedy any injustice caused to Mrs F by being wrongly moved.
37. Mrs F did develop two category two pressure sores and the district nurse advised repositioning from 7 August. Prior to that, the care plan said Mrs F was able to re-position herself in bed and appropriate equipment was being used. Mrs D says her mother had to be supported and was not able to re-position herself, but as this is not in the care plan, I do not have evidence of fault in the care provider’s monitoring of Mrs F’s pressure areas.
38. I have considered very carefully whether the Home did enough to encourage Mrs F to eat and drink. Although her capacity to make decisions about her care was variable, she was able to make her views known and decline food and drink, which she did. On the evidence I have seen, Mrs F lost 1.1kg of weight. She was not referred to a dietitian, there is no evidence she was at high risk of malnutrition and a fluid chart was kept. Whilst there were concerns about dehydration, I have not seen evidence that Mrs F’s refusal of food and drink was due to fault by the care provider; meals and drinks were offered and assistance was given.
39. Mrs D is concerned there was a lack of staffing and training in the Home. The Ombudsman cannot determine this as we are not the regulator.
40. 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. Our guidance suggests that an appropriate remedy for uncertainty and distress is up to £300.

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Agreed action

41. Within a month of my final decision, the care provider has agreed to:
1. Apologise to Mrs D and pay her £200 to remedy the uncertainty and distress caused by fault.
2. Provide training to all care staff on record-keeping, to ensure the records kept are fit for purpose in line with the fundamental standards.
42. The care provider should provide us with evidence it has complied with the above actions.

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Final decision

43. 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