Summary: There was fault in the late Mr X’s care because the Care Home did not have care plans for Mr X. however, there was no fault in the Care Home’s actions when Mr X’s health declined. Staff acted promptly by liaising with the GP, arranging a GP visit and contacting paramedics. The Council which funded the placement will apologise, make a symbolic payment and check the Care Home has up to date care plans in place for council-funded residents.

The complaint

1. Mrs X complained about her late husband Mr X’s care in The Crest Care Home (the Care Home) which the Council arranged and funded. She said the Care Home failed to:
1. Provide adequate catheter and fluid care
2. Notice Mr X was becoming unwell and seek timely medical support.
2. Mrs X complained about missing glasses, a watch and a razor.
3. She said this caused her and Mr X avoidable distress.

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What I have and have not investigated

4. I have investigated the complaints in paragraph two. I have not investigated the complaints about missing possessions because the Care Home said the glasses and watch went to hospital with Mr X. It is unlikely that further investigation of this matter will lead to a different outcome and the injustice from the razor is not significant.

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The Ombudsman’s role and powers

5. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
6. We provide a free service, but we must use public money carefully. We do not start or may decide not to continue with an investigation if we decide:

• The injustice is not significant
• we could not add to any previous investigation by the organisation, or
• further investigation would not lead to a different outcome, or

(Local Government Act 1974, section 24A(6))

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)

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How I considered this complaint

8. I considered Mrs X’s complaint to us, the response to her complaints and documents described in this statement. I discussed the complaint with Mrs X.
9. Mrs X, the Council and the Care Home 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

Relevant law and guidance

10. If a council has reasonable cause to suspect abuse of an adult who needs care and support, it must make whatever enquiries it thinks is necessary to decide whether any action should be taken to protect the adult. (Care Act 2014, section 42)
11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) The Ombudsman considers the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
12. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
13. Regulation 12(i) of the 2014 Regulations says a care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents.
14. Regulation 14 of the 2014 Regulations says the nutrition and hydration needs of residents must be met. They must receive suitable nutritious food and fluid to sustain life and good health, with support to eat and drink if needed.

What happened

15. Mr X had dementia and Parkinson’s disease. He went into the Care Home for two weeks in April 2022 so Mrs X could have a break from her caring role.
16. Mrs X visited Mr X every day until 21 April when she was informed he had tested positive for COVID-19. She also tested positive and did not visit him for the next week.
17. I asked for the Care Home’s care plans for Mr X. It has not provided any care plans. It has provided daily care notes, food and fluid records and records of liaison with others. I have summarised relevant records below from 24 April.
18. On 24 April, Mr X’s catheter bag was emptied several times and the total passed was 550 ml. There was no breakfast recorded, he ate little at lunch and tea. Only 145 ml of fluid is recorded as taken.
19. On 25 April, 650 ml of urine was emptied from the catheter bag. Mr X’s intimate areas were washed and his skin checked with no problems noted. He played a ball game in the lounge. The fluid intake recording is patchy – two cups of tea and a glass of juice. He ate a small amount at meal times.
20. On 26 April:
• Mr X’s catheter bag was emptied several times and he passed 900 ml.
• He took just under two litres of fluid in total throughout the day.
• He ate most of his porridge, had biscuits as a snack, ate very little of the first course for lunch but most of the dessert, some fruit for a snack and ate very little at tea.
21. On 27 April:
• The catheter bag was emptied at midnight and 04:06 and 08:00. 250 ml, 50 ml and 100 ml were passed respectively
• A member of staff spoke to Mr X’s GP at midday, who advised to call an ambulance for Mr X. Paramedics came and checked his oxygen levels and said to encourage fluids
• The catheter bag was noted to be empty at midday. Mr X drank 270 ml of fruit juice at 12.10 and 175 ml at 12.00
• He had sips of fluid at 13:30. He ate all his dessert.
• Catheter bag was emptied at 15:30. 150 ml.
• He ate little of the main meal at tea, ate some cake and a cup of tea
• His catheter bag was emptied of 250 ml at 21.00

22. On 28 April:
• Mr X had 50ml juice at midnight
• Catheter bag was emptied during the night. The amount is not specified
• Mr X had 255 ml tea at 10.15 am, he ate very little porridge
• At lunch time, staff tested Mr X’s urine which was positive for a urine infection. They contacted the GP who said they would prescribe liquid antibiotics and visit later that day
• Mr X was asleep in the lounge in the afternoon
• A practitioner from the GP surgery visited, checked Mr X and found him non-responsive and rang an ambulance
• Paramedics took to hospital as he was not in a good condition and was lethargic.
23. Mrs X told us she visited again on 28 April. She said she found Mr X slumped in a chair, cold to touch and unresponsive. The GP’s records show a practitioner from the surgery had spoken to a care worker who said Mr X had been unwell for the previous two days and they thought he may have a urine infection and were concerned about his swallowing and fluid intake. The practitioner from the GP surgery arrived shortly after Mrs X, examined Mr X and called an ambulance.
24. The note of Mr X’s admission to hospital said his penis was sore, swollen and ulcerated. He was treated for sepsis. The hospital made a safeguarding referral to the Council.
25. Mrs X complained to the Care Home at the start of May. She also complained to the Council. She said she was shocked at his deterioration when she visited.
26. The manager acknowledged Mrs X’s complaint and apologised for not informing her that paramedics had been called to see Mr X on 27 April.
27. Mrs X sent chasing emails to the Care Home for its response to her complaint. The Council advised her there would not be a response to her complaint until it had concluded the safeguarding enquiry.
28. The Council held a safeguarding planning meeting in June. Attendees went through information from the GP, Mrs X and the Care Quality Commission. The conclusion was that staff followed the advice from paramedics who attended on the 27th and the following day called the GP due to continuing concerns. The care to Mr X was deemed ‘reasonable to any person’. The report said that an officer would visit the Care Home to look at the care plans, risk assessments, fluid and catheter charts and daily records. The purpose of the visit was ‘to understand if his decline was apparent and could have been acted on further.’
29. I asked the Council if this follow up visit took place. The Council said it did. The Council provided me with a note of an officer’s visit to the Care Home which said:
• Agency staff were not recording fluid drunk
• On one day, he did not drink three times when offered fluids. But the next day he drank lots
• The recording from 18 April indicated he was not eating or drinking well and was needing more support. This was the start of a decline in health before he tested positive for COVID-19.
• Recording was poor on 23 April
30. The Council’s first response to the complaint said it was satisfied the Care Home had taken appropriate action when Mr X became unwell, did communicate with health and when Mr X’s condition declined, consulted with health again. The Care Home accepted it did not communicate with her and apologised.
31. Mrs X was unhappy with the Council’s response to her complaint and escalated her complaint. The Council’s second response said:
• The care records showed the start of Mr X’s decline was 18 April where he was eating and drinking less
• Fluid input and output was recorded
• Paramedics visited on 27 April, stayed for 40 minutes and asked for staff to encourage fluids and observe. The paramedics decided not to take Mr X to hospital. Paramedics noted his urine looked thick, changed the catheter bag and said it was fine
• There was no evidence to suggest Mr X was left for four days in a state of near-collapse.

Was there fault?

Complaint a: Failure to provide adequate catheter and fluid care

32. There was no care plan for Mr X’s catheter care. This is fault. There should have been a care plan explaining how often to check the bag, how often to change the bag, how to put it on, and the signs staff needed to watch out for and actions they needed to take in case of any problems with the catheter. Mr X’s care was therefore not in line with Regulation 9 which required the Care Home to provide care in line with a care plan which met his needs and preferences.
33. I note Mr X’s catheter bag was checked and emptied several times each day. This evidences that catheter care was provided. And his skin was checked on 25 April and no problem noted. It is likely therefore that the swelling and ulceration noted by the hospital was not present on 25 April and developed after.
34. I note also that there was no care plan for food and fluid. This was fault. Regulation 14 requires the Care Home to provide suitable food and fluid. A nutrition and hydration care plan should have been devised in conjunction with Mr and Mrs X to set out his preferences for eating and drinking, the support he needed to do so and any dislikes and allergies.
35. The Council’s safeguarding investigation failed to recognise the Care Home’s lack of care plans for Mr X. This was in my view an additional fault and calls into question the robustness of that investigation. I note an officer visited the Care Home to inspect Mr X’s care records, but this was after the chair signed off the safeguarding enquiry report. No feedback was given to the chair about whether the officer had looked at Mr X’s care plans and if so whether or not they were adequate. The officer cannot have seen any care plans because none existed. Had this formed part of the investigation while the enquiry was still open, then on a balance of probability, the outcome is likely to have been that there were concerns about the quality of care or at least about the quality of record keeping.

Complaint (b): Failure to notice Mr X was becoming unwell and seek timely medical support.

36. I note staff recorded Mr X’s fluid intake. This was generally below one litre apart from one day. This indicates a risk of dehydration. Staff also recorded food intake which was again low for the few days before Mr X went into hospital. These are signs of potential concern for Mr X’s wellbeing. I am satisfied the Care Home responded appropriately by contacting Mr X’s GP for advice on 27 April, that advice was to call for the paramedic. The Care Home acted on the GP’s advice. I note the paramedics decided not to admit Mr X on 27 April. Mr X’s condition did not improve and he was noted to be lethargic so staff arranged a visit from the GP surgery the following day, who arranged for Mr X to go to hospital urgently. I find the Care Home acted in line with Regulation 12 by securing health input from the GP on consecutive days and by following advice to call paramedics on the 27th. So there is no fault.

Injustice

37. The fault I have identified in complaint (a) has caused Ms X avoidable distress and time and trouble complaining.
38. Ms X feels the Care Home caused or contributed to her husband’s death. There is not enough evidence to support this conclusion.

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Agreed action

39. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the Care Home, I have made recommendations to the Council.
40. Within one month of my final decision, the Council will:
• Apologise to Ms X and make her a symbolic payment of £250 to reflect her avoidable distress
• Carry out a contract monitoring visit to the Care Home to ensure all council-funded residents (including those receiving temporary or respite care) have up to date care plans in place and provide me with a written report of the visit.
41. The Council should provide us with evidence it has complied with the above actions.

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Final decision

42. There was fault in the late Mr X’s care because the Care Home did not have care plans for Mr X. however, there was no fault in the Care Home’s actions when Mr X’s health declined. Staff acted promptly by liaising with the GP, arranging a GP visit and contacting paramedics. The Council which funded the placement will apologise, make a symbolic payment and check the Care Home has up to date care plans in place for council-funded residents.
43. I completed the investigation.

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Investigator's decision on behalf of the Ombudsman