Summary: We upheld this complaint. Mrs Y’s care was not person centred, the Care Provider’s record keeping was inadequate and there was a failure to notice she was becoming unwell. The Care Provider also took too long to respond to the complaint. It has taken some action to remedy the avoidable distress and to avoid recurrence. It will arrange for staff training in effective record keeping and identifying signs a resident may be becoming unwell.

The complaint

1. Mrs X complained about her late mother Mrs Y’s care in Eastham Care Home (the Care Home) owned by Runwood Homes Ltd (the Care Provider). Mrs X complained:
1. The heating in Mrs Y’s bedroom was stuck on extremely hot during the heatwave of July 2022 and she was not moved to a different room
2. Mrs Y only had two baths in three and a half weeks, one of which Mrs X gave her
3. Staff failed to notice Mrs Y was unwell
4. Pressure care was inadequate, Mrs X noticed a pressure sore and asked for a GP visit
5. There was a delay responding to the complaint.
2. Mrs X said this caused her and Mrs Y avoidable 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. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. 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)
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. I considered the complaint to us, the Care Provider’s response and documents described later in this statement.
8. Mrs X 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

9. 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.
10. 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.
11. Regulation 12 of the 2014 Regulations says care must be provided in a safe way including assessing risks to the safety of people using the service and doing all that is reasonably practicable to mitigate risks.
12. 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.
13. Regulation 17 of the 2014 Regulations requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.
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. Mrs Y had dementia and lived in the care home between 24 June and 20 July 2022.
16. The Care Home drew up care plans for Mrs Y describing the care she needed. I have summarised these below:
• She spoke quietly, she had difficulty retaining and processing information. She could make daily decisions, for example, what to wear.
• She could stand with a frame and take a few steps. She needed a wheelchair for longer distances.
• She needed support with personal hygiene. She could wash her hands and face herself. She needed help with dressing and undressing. She chose her own clothes and liked to look feminine.
• Staff should record Mrs Y’s nutritional intake. She was a fussy eater, but she could state her preferences. The care plan said nothing about fluid. It said she needed prompting and encouragement during meals.
17. Mrs Y had a catheter when she came into the care home. Staff contacted the district nurse about this as it was supposed to be temporary while Mrs Y was in hospital. The Care Home’s records indicate the district nurse removed the catheter on 30 June.
18. The Care Home kept daily records of Mrs Y’s care. The first entry on admission to the home noted Mrs Y’s urine was dark and she needed encouragement to drink. Other entries show she had support to bathe on 1 July (Mrs X assisted) and on 11 July. Staff also noted generally that Mrs Y received ‘personal care’ most days. The notes did not give details or a description about what personal care was given on each occasion. (for example: full body wash, wash hands and face, clean teeth and so on)
19. They daily notes did not give details of Mrs Y’s fluid intake, they just noted when staff encouraged or provided fluids, but not how much she drank. On several occasions between 14 and 17 July, Mrs Y declined food and fluid. On 17 July, she vomited at breakfast. Staff contacted the GP for advice and were advised to call 999. There was going to be a wait for an ambulance, so Mrs X took Mrs Y to hospital. The daily notes said Mrs Y had not been drinking enough and seemed dehydrated. Mrs Y returned from hospital later that day, having been diagnosed with a urine infection and was prescribed antibiotics. Staff noted they were to encourage her to take fluids and to eat fruit to help with hydration.
20. The records continued to have entries saying Mrs Y was refusing fluid, but there was no recording of her intake. The GP came to see her on 20 July. Mrs X was also present when the GP attended. Mrs X was admitted to hospital.
21. The Care Home kept a body map for Mrs Y. This had a bruise marked to the left forearm. There was no record of any pressure sores.
22. Mrs X complained to the Care Provider in August raising the same issues as in her complaint to us.
23. The Care Provider did not respond to the complaint until Mrs X chased for a response in November. The Care Provider apologised for the delay. The complaint response in January 2023 said:
• It was sorry for not moving Mrs Y to a cooler room in July. This was due to poor management. The manager no longer worked for the company
• Mrs Y resisted personal care on occasion. Staff should have worked harder with them to gain insight into how to support Mrs Y.
• It acknowledged Mrs X supported her mother to bathe when staff should have relieved her of this
• It was disappointing that she had to identify concerns about her mother’s health. The team was in regular contact with the GP about medication, infection and fluid intake. It was sorry they could not intervene quick enough to ensure Mrs Y did not deteriorate while in their care
• The company offered a 50% refund.
24. The Care Provider shared training records with me which show staff have received training in dementia awareness and fluids and nutrition.

Findings

The heating in Mrs Y’s bedroom

25. The Care Provider upheld this complaint. This environment was unsuitable and potentially unsafe for Mrs Y given the extreme weather last summer. The Care Provider should have resolved this immediately. Care was not in line with Regulation 12 which was fault. This would have caused Mrs Y avoidable distress and discomfort.

Bathing

26. The Care Provider upheld this complaint. Care was not in line with Regulation 9. Mrs Y’s care plan did not state her preferences regarding bathing. It should have been tailored to her preferences.
27. Daily records about ‘personal care’ were generic and did not describe the care Mrs Y received. I cannot tell from the records what care she received. Record keeping was not detailed enough to be in line with Regulation 17 and this was fault. It meant there was uncertainty about the care Mrs Y received.

Failure to notice Mrs Y was unwell

28. There is no general requirement to monitor a resident’s fluid intake, unless risk dictates. The Care Home should have drawn up a temporary care plan for Mrs Y on 17 July when she was diagnosed with a urine infection. It is also normal practice to record food and fluid intake for the first week of a resident’s admission and this was not done in Mrs Y’s case. I note an entry on the first day said Mrs Y’s urine was dark and at that time she had a catheter. I would have expected food and fluid to have been recorded on a chart for the first week or so given dark urine is a sign of a lack of hydration and then for a review to have taken place to consider whether this needed to continue. The failure to have in place fluid charts for the first week of admission was not in line with Regulations 14 or 17 and was fault.
29. In any event, I consider staff should have started a food and fluid chart around 15 July because this is when entries in the daily records said she was refusing fluid and food. It was therefore key to have an accurate record of her fluid intake to minimise the risk of dehydration. The failure to do so means care was not in line with Regulations 14 and 17 and this was fault. A failure to drink is a sign a person may be becoming unwell. The Care Provider acknowledged in its complaint response that they did not intervene sooner.

Pressure care was inadequate, Mrs X noticed a pressure sore and asked for a GP visit

30. There was no pressure/skin integrity care plan for Mrs X, no entry on the body map indicating a pressure sore and no record of any discussion between Mrs X and staff about her raising concerns about this. I have no reason to doubt Mrs X and as I have already noted, the Care Home’s record keeping was poor. The Care Provider acknowledged in its complaint response that Mrs X had to report concerns about Mrs Y to the GP. My view is care was not in line with Regulation 17 or 12(i) and this was fault. The injustice to Mrs Y is unclear because of the lack of records.

There was a delay responding to the complaint.

31. The Care Provider took five months to respond to the complaint. It has apologised for the delay and explained this was due to staff changes. The delay was unacceptable and was fault. It caused avoidable inconvenience and frustration.

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Agreed action

32. The Care Provider has already apologised and waived half the fee. This action is in line with our published guidance where the person most affected has died. There are no grounds to recommend a full refund of fees because Mrs Y received some care, albeit not in line with accepted standards.
33. The Care Provider has evidenced some training for staff including dementia care and nutrition and hydration. The Care Provider has agreed to provide training for care staff in:
• Record keeping
• Identifying signs a resident may be becoming unwell.
34. The Care Provider should provide us with evidence it has complied with the above actions. It has agreed to do so within three months of this statement.

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Final decision

35. Mrs Y’s care was not person centred, the Care Provider’s record keeping was inadequate and there was a failure to notice she was becoming unwell. The Care Provider also took too long to respond to the complaint. It has taken some action to remedy the injustice. It will ensure staff receive training in effective record keeping and identifying signs a resident may be becoming unwell.
36. I have completed the investigation.

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Investigator's decision on behalf of the Ombudsman