Summary: Mrs X complains the Council was at fault in the way staff at its care home cared for her mother Mrs Y due to a delay in seeking medical assistance causing her to be unwell. We found fault as the care documentation was not as robust as it could have been causing uncertainty for Mrs X over the care Mrs Y received. We have recommended a suitable remedy, so have completed our investigation.

The complaint

1. The complainant who I shall refer to here as Mrs X complains there were failings in the way the Council dealt with her concerns about the care her mother, Mrs Y received while resident in a Council owned care home. Mrs X says the staff failed to notice subtle changes in Mrs Y which indicated she was becoming critically unwell despite the family raising concerns. Mrs Y was eventually admitted to hospital with a serious medical condition causing distress to Mrs Y and the family. Mrs X alleges that if staff had noticed the changes in Mrs Y’s condition sooner, then her admission to hospital would not have been so serious.
2. Mrs X also complains the Council failed to address the outcomes she sought in her complaint made in September 2022.

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The Ombudsman’s role and powers

3. 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)
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. 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

6. I read Mrs X’s complaint and spoke with her about it on the phone. I made enquiries of the Council and considered the information received.
7. Mrs X and the Council 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

Background information

Standards in care

8. The Health and Social Care Act 2008 (regulated activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve.
9. One of the fundamental standards says care providers must keep accurate, complete and current records for each person in their care, including a record of the care and treatment provided and decisions about care and treatment.
10. When investigating complaints about the standards of care in a care home, the Ombudsman considers if the 2014 regulations and the fundamental standards have been met. If they have not, we consider whether any identified faults have resulted in injustice.

What happened in this case

11. What follows is a brief chronology of key events. It does not contain all the information I reviewed during my investigation.
12. Mrs Y stayed at the care home for a short assessment period. Mrs Y had medical conditions including dementia and COPD for which she used inhalers. While resident at the care home Mrs Y was treated for a chest infection and prescribed antibiotics for a short period.
13. The key period leading up to Mrs Y’s admission to hospital was from 6 to 10 September 2022. During 6 to 8 September 2022 Mrs X, Mr Y and other family members visited daily and took Mrs Y out. The care home has no record of the family raising any concerns with staff. Its documentation recorded Mrs Y showed no signs of being unwell. Care staff recorded Mrs Y did need encouragement to eat at mealtimes and occasionally needed help with meals.
14. On 8 September 2022 Mr Y said Mrs Y was moving to a different care home on 13 September 2022 and thanked staff for the care received. Care home staff reported Mr Y was positive about the home, did not make comments indicating health concerns about Mrs Y and said the family were only moving her for financial reasons.
15. The care records for the morning shift on 9 September did not note any concerns about Mrs Y. The afternoon shift noted Mr Y took Mrs Y out on a trip. Care staff noticed Mrs Y was coughing, sneezing and not seem herself on return. An Assistant Unit Manager (AUM) told the care home’s fact-finding investigation staff advised Mrs Y was coughing and sneezing but from their own observation Mrs Y was not continually presenting with symptoms. The AUM said Mrs Y was not showing signs of wheezing, shortness of breath, a persistent chesty cough, breathing difficulties or a raised temperature. The AUM told staff Mrs Y was regularly using inhalers for COPD which could explain the cough. But the AUM did not record their actions and views on this in Mrs Y’s medical notes.
16. The AUM reported Mrs Y declined medication that evening and said she was not in any pain. Mrs Y appeared briefly agitated but was ‘smiling’ not in distress or displaying any pain for the rest of the shift. The AUM recorded in the end of shift notes that Mrs Y was ‘unsteady, coughing and feeling cold, declined medications, declined LFD test’. The AUM told the fact-finding investigation the wording made Mrs Y’s symptoms sound ‘worse than they were’ and had discussed the symptoms in more detail with the next AUM at handover. The AUM believed the symptoms were a response to Mrs Y being out and having the autumn Covid-19 vaccine booster that morning. The AUM could not recall why they wrote Mrs Y was unsteady but explained occasionally Mrs Y held on to furniture while she walked. The AUM said they did not have any concerns about Mrs Y’s health and would continue monitoring her health as with all residents.
17. Care staff took Mrs Y’s temperature that night and recorded it as within normal range. In the morning of 10 September 2022, care notes recorded Mrs Y declined her medication again and appeared disengaged. The AUM called Mr Y to discuss Mrs Y’s change in behaviour and Mr Y agreed to help encourage her to take medication on his visit. The AUM and Mr Y discussed that one of Mrs Y’s medications had been stopped and this could be a link to her current presentation. Mr Y did mention he had noticed a change in Mrs Y’s behaviour. The care home says was the first report by staff of Mr Y raising concerns about Mrs Y’s health. The AUM continued with the medication round, was aware Mr Y visited but he did not ask to see the AUM. The care home believes that Mr Y then called Mrs X after his discussion with the AUM.
18. The AUM reported in the care notes Mrs Y became distressed after lunch, holding her stomach and appeared in discomfort. Care staff then helped Mrs Y with a toileting issue. The AUM considered this was cause of Mrs Y’s discomfort, behaviour, a reflection of her health conditions, stopping medication, COPD, Covid-19 vaccine and being a new client settling in. The AUM did not consider Mrs Y was seriously unwell but decided to seek medical advice because she was refusing medication.
19. Mrs X called for an update following Mr Y’s contact and discussed Mrs Y’s health and medication with the AUM. The AUM reports it was a general conversation. Mrs X asked the AUM to call 111 who advised it was already planned due to Mrs Y still not taking her medication. The AUM reports they ‘risk assessed’ the urgency of the 111 call as the medication round needed completing. Due to need for clients to have medicine at certain times the AUM decided to finish the round first as Mrs Y not seem in any immediate danger. The AUM reported Mrs X sitting down and reading a magazine. Care staff made a call to 111 later that afternoon and Mrs Y eventually admitted to hospital.
20. Mrs X raised concerns with the Council and care home that staff failed to notice Mrs Y’s health was declining and could have acted sooner to call for medical assistance. The Council responded to the complaint with the care home manager carrying out a fact-finding investigation of events, speaking to staff and checking records. The Council considered the information and responded to Mrs X.
21. The Council found care home staff did not recall Mr Y saying several times he did not think Mrs Y was herself. It found Mr Y and the family had taken Mrs Y out most days and had not reported concerns to staff or stopped taking her out. There had been no concerns raised by Mrs Y’s family after she took antibiotics for the chest infection. There were also no symptoms other than the occasional sneezing, to warrant the AUM considering it necessary to call a GP or seek further support.
22. The Council noted Mrs Y was a new client who had a chest infection after admission and staff were still getting to know what was normal for her. Mrs Y’s family took her out daily and visited, limiting the time staff spent in observing and interaction with her. It noted the difficulty in diagnosing the illness and the care home was not a nursing facility. The Council found Mrs Y did not have any rash or fever. And her symptoms could have been for other reasons such as COPD, changes in medication and the recent Covid-19 vaccine. The care home reported that at no time did Mrs Y appear seriously or dangerously unwell.
23. The Council accepted there were some areas for learning and reminders for care home staff. These were:

• To ensure that staff use correct recordings to enable robust information to be passed to each other, for staff to think about the wording they are using and how this can be misconstrued when reflected upon.
• If the AUM has numerous tasks to complete and some of which may be urgent or need to be completed in a timely manner, then the staff member is to request support from an AUM on a different floor.

24. The care home sent a copy of the full fact-finding information with outcome to the CQC. It also raised a safeguarding concern to the Portsmouth Multi Agency Safeguarding Hub (MASH) to review the alleged neglect of Mrs Y’s health. It confirmed staff would consider if there were any further learning to be gained following a review.
25. MASH considered the safeguarding concern and was satisfied with the fact-finding response to Mrs X. So, it closed the safeguarding concern as it did not consider on balance there was any evidence of clear omissions in Mrs Y’s case.
26. Mrs X remained unhappy with Council’s investigation and alleged care home staff failed to notice Mrs Y was unwell with the serious medical condition. This was despite Mr Y, and other family members, including Mrs X raising concerns about Mrs Y’s health to staff members. Mrs X said Mr Y felt no one was listening to him or acting on his concerns. Mrs X said the staff wrongly misread the situation to believe it was the symptoms of a Covid-19 vaccination. Mrs X says she rang care home and spoken to an AUM, and it was through her persistence they called 111.
27. The Council asked what outcomes Mrs X wanted as she remained unhappy with the response. Mrs X explained her outcomes including an apology for failing to care appropriately and safely for Mrs Y and recognition the family were seeking Mrs Y’s best interest. Mrs X also wanted confirmation the complaint had helped improve care documentation and training needs.
28. The Council considered Mrs X’s comments. It reviewed the investigation and response received. But was satisfied it had carried out an investigation appropriately and could not add anything further.

My assessment

29. The Council’s investigation has shown that on occasions the care home’s record keeping did not contain a full explanation for decisions and the wording was unclear. This is fault by the Council as the fundamental standards require records to be accurate and complete including decisions about care and treatment. The lack of a full explanation and clear wording causes uncertainty to Mrs X and the family as to whether the Council was dealing appropriately with Mrs Y’s care. However, while I find fault, I consider it unlikely the outcome would have been any different. This is because the records show care home staff were monitoring Mrs Y’s health, aware she was declining medication and were due to seek medical assistance on the day of Mrs X’s telephone call.
30. The Council and care home have accepted the need to improve its record keeping. But I consider the Council should also apologise to Mrs X and the family for the uncertainty they have been caused because its record keeping was not as robust as it could have been on occasions. The Council and care home have acknowledged some areas for learning on its record keeping. And to improve its care documentation which was an outcome Mrs X was seeking.
31. Mrs X complained the care home should have sought medical assistance for Mrs Y sooner than it did. We cannot say whether assistance should have been sought sooner based on Mrs Y’s presentation. This was a matter for the professional judgement of the care home staff. We do not question the merits of a decision taken using officers’ professional judgement unless we have evidence of fault in the way it was taken. I do not consider that to be the case here.
32. This is because the care home records show staff were monitoring Mrs Y’s health and were aware of a change in her behaviour. The AUM explained why staff did not call for medical assistance sooner due to Mrs Y’s presentation, her ongoing medical conditions and she did not appear to be seriously unwell. While Mrs X may not agree, it was a decision for care home staff to take using their professional judgement. There is no evidence of fault by the Council on this issue.
33. The Council referred the matter to MASH as we would expect it to do, to assess whether there was a safeguarding concern about neglecting Mrs Y’s health. MASH assessed all the care home records, the fact-finding investigation and did not find any evidence of clear omissions regarding Mrs Y. So, there were no safeguarding concerns or evidence of neglect. Mrs X’s complaints have been fully considered by the Council and MASH, so I do not consider we can achieve a different outcome for Mrs X through further investigation.
34. Mrs X raised concerns the Council failed to respond to the outcomes she wanted because of her complaint. It is usual practice to ask what outcome someone is seeking when making a complaint. The Council confirmed it had considered Mrs X’s complaint, was satisfied it had carried out an appropriate investigation and unable to add anything further.
35. I consider it would have been helpful for the Council to acknowledge Mrs X's requested outcomes. And to explain why it did not consider it necessary to meet them due to its decision on the complaint. However, I do not intend to pursue the matter further. This is because some of Mrs X’s desired outcomes have now been met as the Council is ensuring an improvement in the care home’s documentation as part of learning from her complaint. And I have recommended the Council apologises to Mrs X and the family for the uncertainty caused by the lack of full explanations and occasional unclear wording.

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Agreed action

36. Within a month of my final decision the Council will:
• Apologise to Mrs X for the uncertainty caused to her and the family by the care home’s documentation failing to contain a full explanation for decisions and the occasional unclear wording.
• Explain the action it has taken to improve the care home’s care documentation noted as part of learning from the complaint.
37. The Council should provide us with evidence it has complied with the above actions.

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Final decision

38. I am completing my investigation. I have found fault by the Council as its care documentation was not always robust causing uncertainty for Mrs X as to the care Mrs Y received. I have recommended a suitable remedy in this case.

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Investigator's decision on behalf of the Ombudsman