Summary: Mrs E complained the Care Provider failed to provide her late mother, Mrs F, with an acceptable level of care when she was a resident at its care home. We find the Care Provider’s failure to maintain complete records caused Mrs E worry and uncertainty about the care Mrs F received. The Care Provider has agreed to our recommendations to address this injustice.

The complaint

1. Mrs E complained the Care Provider failed to provide her late mother, Mrs F, with an acceptable level of care when she was a resident at its care home. She says the Care Provider failed to properly understand Mrs F’s medical conditions and it failed to recognise when her health was deteriorating. She adds it failed to listen to concerns from family members and there was poor communication with her specialist medical professionals. She also says there was no nutritional and hydrational support, poor personal care, and a failure to put risk management measures in place to prevent Mrs F’s falls.
2. Mrs E says she is devastated Mrs F died suffering. She says the Care Provider’s failings have caused her anxiety and distress.

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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 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)
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. 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.
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)

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How I considered this complaint

7. I considered information from Mrs E. I made written enquiries of the Care Provider and considered information it sent in response.
8. Mrs E 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

Care home regulation and guidance

9. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers which 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. 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.
11. Regulation 9 says care and treatment must be appropriate and meet service users’ needs.
12. Regulation 17 says care providers should maintain an accurate, complete, and contemporaneous record in respect of each service user.

What happened

13. Mrs F was a resident at the Care Provider’s care home, Waltham house care home. She initially went in for respite care in July 2021 after she was discharged from hospital but ended up staying long-term. Mrs F had Lewy Body Dementia and Parkinson’s disease.
14. The pre-admission form from the hospital said Mrs F needed assistance with her personal care and she also needed assistance and prompting with eating and drinking. It also said she had a history of falls and she needed help with mobilising.
15. Mrs F went to see a specialist Parkinson’s nurse in October. Mrs E and her sister said they were concerned Mrs F was not getting enough support from care home staff. The nurse told Mrs E and her sister to ensure staff weighed Mrs F weekly. She sent a letter to Mrs F’s GP with her advice.
16. Mrs F had an unwitnessed fall out of bed on 8 November. Staff called 111 and the paramedics attended. They checked Mrs F and advised care staff to monitor her. Later that day, Mrs F complained of chest pain. Staffed called 111 again and the paramedics assessed her. They said she was fine and advised staff to continue with pain relief.
17. Mrs E took Mrs F to hospital several days later after she was complaining about pain and discomfort. She was diagnosed with a slight chest infection and put on antibiotics.
18. The district nurse visited Mrs F on 19 November. She did not raise any concerns about Mrs F’s health.
19. Mrs F had another fall on 30 November. She did not have any visible injuries, but staff observed her throughout the day for bruising.
20. Mrs E contacted a local hospice and the GP surgery and said she was concerned about Mrs F’s health. The nurse at the hospice phoned the Care Provider and spoke to a member of staff about Mrs E’s concerns. The member of staff advised the nurse they had no imminent concerns about Mrs F’s end of life status, but if they did they would contact her GP.
21. Mrs E made a referral for a nurse to assess Mrs F. The district nurse visited Mrs F on 7 December. She said she was frail but did not qualify for end of life care. However, she agreed to refer the matter to Mrs F’s GP for a review and she said she would also request anticipatory medication. Anticipatory medication is medication that someone will have access to if they develop distressing symptoms. The nurse said Mrs F qualified for a profiling bed. Profiling beds are used for patients with poor mobility. She also said it was likely Mrs F would qualify to be fast tracked to a nursing home for palliative care. Mrs F’s family considered this option but decided nursing care was not appropriate as Mrs F would have been put in isolation for two weeks.
22. The Care Provider weighed Mrs F on 8 December and noted her weight had significantly decreased. It made a referral to a dietician through Mrs F’s GP. It also made a referral to an occupational therapist due to concerns about Mrs F’s mobility after her falls.
23. A district nurse visited Mrs F on 10 December. She advised care home staff to apply cream to address Mrs F’s inflamed skin, but she did not raise any concerns that Mrs F qualified for end of life care.
24. The nurse team leader spoke to a member of staff at the care home a couple of days later. The member of staff said they did not believe Mrs F qualified for end of life care, but she had lost weight and was eating and drinking a small amount. The team leader told staff to continue to monitor Mrs F and report any concerns to the nursing team.
25. Mrs E called the GP’s surgery and asked to bring forward the scheduled visit. The GP visited later that day and confirmed Mrs F qualified for end of life care and it was agreed she would go to a hospice. The GP noted the form for the anticipatory medication was not in place. This meant it could not be administered. The notes state Mrs F’s daughter agreed to collect the form. Mrs E disputes this.
26. Mrs F went to the hospice the following day. She sadly died within a few hours of reaching the hospice.
27. Mrs E complained to the Care Provider about the care it provided to Mrs F. She said it failed to understand Mrs F’s medical conditions. She also said the Parkinson’s nurse gave a clear pathway to follow, including a profiling bed and checking her weight weekly but staff failed to implement it. She also said it failed to listen to family member’s concerns, and it failed to re-evaluate matters when it became clear Mrs F’s health was deteriorating.
28. The Care Provider responded to Mrs E’s complaint. It said it weighed Mrs F regularly and she had a steady weight gain until October. She began to lose weight and then staff weighed her every two weeks. Staff also made a referral to a dietician due to further weight loss. It said it liaised with the district nurse when the family raised concerns Mrs F was coming to the end of her life.

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Analysis

29. Mrs E says the Care Provider’s communication was poor with Mrs F’s medical professionals and it failed to understand her medical conditions. She also says it failed to listen to her concerns about the deterioration in Mrs F’s health and take appropriate action.
30. The records show staff consulted with the district nurses, the GP, and the paramedics when appropriate. It took their advice and followed through with any action points.
31. The Care Provider was aware of Mrs F’s family’s concerns about the deterioration in her health. It consulted with the nursing team on several occasions. Care home staff did not initially consider Mrs F qualified for end of life care. Although Mrs E strongly disagrees, it was their professional judgment. The district nurse visited Mrs F on two occasions and agreed she did not qualify for end of life care. The Care Provider agreed to keep the matter under review. Mrs F’s GP had been informed of the concerns and agreed to complete an assessment.
32. Mrs E says staff should have ensured the form was in place for Mrs F to receive anticipatory medication. The care home, as a residential home, has no legal responsibility to administer medication. It is the responsibility of the administering professional, in this case the district nurse, to ensure the correct forms are in place.
33. Mrs F’s care plan said staff should monitor her weight monthly and if her weight changed to contact the GP or dietician. Staff weighed Mrs F twice in July, and then once every month. Mrs F was putting on weight until October. When she was weighed in November, she had lost nearly two kilograms of weight. The Care Provider then decided to weigh Mrs F every two weeks because of this weight loss. When it weighed her two weeks later, she had lost nearly 12 kilograms. The Care Provider acted in accordance with Mrs F’s care plan and its policy and referred the matter to a dietician through her GP.
34. Mrs E says the Parkinson’s nurse told the Care Provider in October to weigh Mrs F every week, but it failed to do so. The letter from the Parkinson’s nurse was addressed to Mrs F’s GP, and not the Care Provider. There is no evidence the nurse got in touch with the Care Provider directly and advised it to weigh Mrs F weekly. There is also no evidence the GP sent this information to the Care Provider. Therefore, I cannot criticise the Care Provider for not weighing Mrs F weekly in line with the nurse’s recommendation.
35. Mrs F’s care plan said she required a full body wash twice daily, as well as help with her oral hygiene. The daily notes are inconsistent regarding what personal care and oral hygiene Mrs F received. There are some days when no personal care is recorded. It is also not clear whether Mrs F’s oral hygiene needs were met.
36. I have looked at the food and fluid charts to see whether the Care Provider met Mrs F’s nutritional and hydrational needs. There are some entries missing for breakfast, and so it is not clear whether Mrs F was offered breakfast and she declined it, or it was not offered at all. The record keeping of Mrs F’s fluid intake is inconsistent. There are some occasions on the fluid chart when it states Mrs F did not have an any fluids, but in the daily notes it suggests she did.
37. Regulation 17 of the CQC guidance is clear that all care providers should maintain accurate, complete, and contemporaneous records in respect of each service user. Accurate record keeping is vital for the safe delivery of care. It is not clear whether the Care Provider’s failure in record keeping had a detrimental impact on Mrs F’s health. However, it has caused some worry and uncertainty for Mrs F’s family about whether her personal care needs and nutritional and hydrational care needs were met during her stay at the care home.
38. Mrs E says the Care Provider failed to put risk management measures in place to prevent Mrs F’s falls. The Care Provider’s policy states residents who have experienced recurrent falls will be referred to a suitably qualified health care professional for further assessment. The Care Provider referred Mrs F’s repeated falls to an occupational therapist and so it acted in accordance with its policy. Staff also helped Mrs F to get in and out of bed and two carers supported her with her mobility after her falls.

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Agreed action

39. To address the injustice caused, by 31 May 2023 the Care Provider has agreed to:

• Apologise to Mrs E.
• Pay Mrs E £200 for her worry and uncertainty.

40. By 29 June 2023 the Care Provider will:

• Remind all care and support staff at the care home the importance of maintaining complete and accurate records of a service user’s food and fluid intake and personal care needs. This reminder should give an overview of the procedures in place and how to ensure best practice.

41. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

42. I have ended my investigation and uphold Mrs E’s complaint. I have made recommendations the Care Provider has agreed to carry out.

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Investigator's decision on behalf of the Ombudsman