Summary: Mrs X complains there were failings in the care and support provided to her mother Mrs Y while at a care home run by the care provider causing pain and distress to Mrs Y and the family. We found fault as the care provider’s documentation was not always accurate and complete. The care provider has accepted the errors in documentation and already apologised to Mrs X which is suitable action for it to take. So, we have completed our investigation.

The complaint

1. I have called the complainant Mrs X. She complains for her mother Mrs Y there were failings in the level of care and support provided to Mrs Y by Mariposa Care Group Limited, at a care home in June 2022. Mrs X says the failings led to Mrs Y developing pressure sores and a urine and mouth infection. This caused Mrs Y pain and distress and she needed to be admitted to hospital. Mrs X says on admission to hospital Mrs Y was found to be dehydrated and malnourished.
2. Mrs X complains the care provider falsified its records of the care given to Mrs Y and failed to notice her deteriorating health in June 2022. Mrs X says the care provider failed to ensure Mrs Y received swift, appropriate medical care causing distress to Mrs Y and her 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 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. We provide a free service but must use public money carefully. We may decide not to start or continue with an investigation if we believe:

• the action has not caused injustice to the person who complained, or
• the injustice is not significant enough to justify our involvement, or
• it is unlikely we could add to any previous investigation by the care provider, or
• it is unlikely further investigation will lead to a different outcome, or
• we cannot achieve the outcome someone wants, or
• there is another body better placed to consider this complaint.

(Local Government Act 1974, sections 34B(8) and (9))

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 have read the papers submitted by Mrs X and spoken to her about the complaint. I considered the care provider’s comments about the complaint and the supporting documents it provided.
10. 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

Fundamental standards of care

11. 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 below which care must never fall. The standards include:
• 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.
• Good governance (Regulation 17): Providers must maintain securely an accurate, complete and contemporaneous record in respect of each service user.
• Duty of candour (Regulation 20): Providers should be open and transparent with people who use their services and other relevant persons acting lawfully on their behalf. The CQC says the regulation promotes openness and honesty at all levels as an integral part of a culture of safety that supports organisational and personal learning. It says care providers should apologise when things go wrong.

Background to the complaints

12. What follows is a brief chronology of key events. It does not contain all the information I reviewed during my investigation.
13. Mrs Y was in her late 90’s and diagnosed with several medical conditions. Mrs Y went to stay in Sovereign Lodge Care Home in 2017 (the Home) operated by Mariposa Care Group Limited (the care provider). The Home provided residential care. The care provider’s care records showed from May 2022 Mrs Y’s health remained stable. But in early June 2022 Mrs Y showed signs of urinary incontinence and needed help with toileting. Mrs Y also appeared slower when mobilising.
14. On 7 June 2022 Mrs Y’s GP prescribed a mouth gel for oral thrush as Mrs Y complained of a sore mouth. On 8 June 2022 the Home contacted the Care Home Support team (CHST) due to Mrs Y’s symptoms when toileting. CHST advised the Home to obtain and send a urine sample for analysis. The Home told Mrs X’s brother Mr Z.
15. Mrs Y’s GP received the results from the sample on 9 June 2022, confirmed Mrs Y had a urine infection (UTI) and prescribed antibiotics. The Home told Mr Z and reported Mrs Y was increasingly confused and feeling unwell.
16. On 10 June 2022 Mr Z reported Mrs Y had called him several time during the night and appeared confused. A district nurse reviewed Mrs Y and prescribed two antibiotic creams due to a suspected fungal infection on Mrs Y’s buttocks.
17. Mrs Y completed the antibiotic course for the UTI on 12 June 2022. The care records reported Mrs Y as sleepy, unsettled, and confused when awake and feeling nauseous. A district nurse visited Mrs Y as she had sore heels affecting her mobility. The district nurse reported no obvious skin integrity issues. The care notes report Mrs Y more settled the next day but still confused. The care provider’s food and fluid charts recorded Mrs Y had a reduced food and fluid intake.
18. The Home contacted Mrs Y’s GP on 14 June 2022 as she had a rash on her face. The GP advised the Home call the CHST who visited her later that day. Mrs Y had an unseen leg injury on 15 June 2022. Mrs Y said she had ‘banged her leg on a chair when standing up’. The Home called the district nurse to assess and dress the injury. The GP saw Mrs Y and considered the rash a possible reaction to the antibiotics for the UTI so arranged for a blood sample.
19. The Home contacted Mrs Y’s GP on 16 June 2022 as she was having difficulties with her speech because of fluid. The GP considered it may be due to an infection on Mrs Y’s tongue and noted Mrs Y health declining with her immune system becoming low. The GP swabbed Mrs Y’s tongue, advised on medication and spoke to Mr Z.
20. The care notes report Mrs Y was settled and slept but appeared to choke on secretions when she woke up. Mrs Y’s condition worsened during the day. Staff at the Home called for an ambulance and Mrs Y taken to hospital.
21. The care provider contacted the hospital the next day. The hospital advised Mrs Y was unwell with a possible UTI and unable to swallow properly. Mrs Y remained in hospital and sadly passed away a few days later.

Mrs X’s complaints

22. Mrs X complained to the care provider. Mrs X’s complaints included:
• Concerns the Home neglected its duty of care towards Mrs Y as it did not have suitably experienced staff and systems in place to care for her. Mrs X considered Mrs Y was vulnerable and the neglect of care resulted in her developing a UTI and pressure sores ultimately leading to her death.
• Mrs Y had thrush in her mouth causing difficulties in eating and drinking. So, she was severely dehydrated, malnourished, and suffering with pressure sores when admitted to hospital.
• The Home altered its records when sending them to Mrs X so they read that Mrs Y was content and eating meals when she would have been unable to do so.
• Concerns over whether Mrs Y received all the medication she was prescribed as some were not noted on her Medicines Administration Record (MAR chart).
23. Mrs X also complained to the CQC who carried out an unannounced inspection of the Home. The CQC said it carried out the inspection partly due to notification of an incident following which a person using the service had died. The information indicated concerns about the management of risk to people accessing timely health care. The inspection examined those risks. It found no evidence that people were at risk of harm from this concern. CQC gave the Home an overall rating of ‘good’.
24. The care provider held a reflective practice assessment with staff to discuss Mrs Y’s care and the complaint raised.

The care provider’s response to Mrs X’s concerns

25. The care home staff considered they gave much input to Mrs Y’s care during her last week at the care home. This also included input from visiting medical professionals such as the GP, CHST and district nurses. So, Mrs Y received plenty of care. The care provider noted the GP had advised Mr Z that Mrs Y’s presentation was a natural deterioration of someone of Mrs Y’s age. Mrs X says Mr Z has no recollection of this conversation.

Medications

26. The care provider noted that Mrs Y was allergic to a medicine. This was recorded on her care plan, and the Home had a risk assessment in place. But had not been noted on her MAR chart as required.
27. It also noted Mrs Y’s falls assessment recorded she was on antipsychotic medication which was not the case. The care provider said the record had been initially ticked in error but not noted or corrected at each monthly review. The care provider apologised to Mrs X for the errors and for causing any unnecessary alarm.

Bedsores

28. The care provider confirmed it assessed Mrs Y while she was at the Home using the Waterlow scheme which indicates risk for a pressure ulcer. This indicated Mrs Y was not at risk. The Home had cared for Mrs Y for five years and there had been no previous issues.
29. The care provider advised the district nurses prescribed Mrs Y with two creams for her buttocks on 10 June 2022. Care home staff signed they had applied one of the creams but did not record applying the second one. The care provider could not find a reason why staff did not apply the second cream.
30. Discussions at the reflective practice assessment noted the district nurses often prescribed two creams but advised staff to only use one if needed. This would have been in a verbal conversation between senior staff and the nurses and not documented. The care provider confirmed staff did not report or document that Mrs Y’s skin had developed breaks when applying the one cream.
31. The care provider says the district nurses came to the Home at least twice a day so would have raised any concerns about Mrs Y’s skin integrity breaking down. And the nurses would have discussed this with senior staff if there were concerns. In addition, the Home would have looked at providing an alternative mattress for her. But there were no concerns raised about Mrs Y’s skin.
32. The care provider comments many professionals saw Mrs Y before and after being admitted to hospital. So, if any professionals had concerns about skin damage or neglect, they could have reported it to the local council’s safeguarding team according to protocol. The care provider was not aware of concerns being reported and was not contacted by the safeguarding team.

Changing care records

33. The care provider confirmed it uses an electronic care plan system with staff being able to input data into handheld devices. This includes a happiness recording showing Mrs Y as content. Once staff make record on the handheld devices it cannot be edited or altered without being obvious and so an advantage of the electronic care records. The care provider confirmed there are no changes showing in Mrs Y’s electronic care records.
34. The care provider checked with its care plan system provider to investigate what may have happened to account for the different versions of the care plan Mrs X received. It found it was either the fault of the printer function or server not pulling through the sliders on the happiness recording. This appeared to show missing information in one version which was then visible on the next printed version.

Eating and drinking fluids

35. The care provider reported Mrs Y enjoyed her meals and her stable weight showed she was having a good dietary intake. The care provider supplied Mrs Y’s food and fluid charts. And said the care records showed that staff did not report, or document Mrs Y could not eat or drink because of her sore mouth or general health. But the food and fluid charts showed Mrs Y had a variable intake after the diagnosis of oral thrush and a UTI. When she was refusing food, staff would encourage her to eat and drink. But as Mrs Y had capacity to make decisions it had to respect her refusals.
36. The care provider noted Mrs X’s concerns the care records showed Mrs Y had eaten meals when her mouth was too sore to eat. Mrs X alleged the Home changed the entries to make them look more credible. The care provider advised again that it cannot see any changes in Mrs Y’s electronic care notes. It considers there may be an issue with the handheld device used by staff to record a supper choice for residents. This was because it did not serve a main meat dish as a supper choice recorded as Mrs Y’s meal.
37. The care provider intended to ask its care system supplier to check the choice available for input. And its senior staff would closely monitor what had been added to the care notes.

Reflective practice assessment

38. The assessment found some areas for improvement including:
• Noting communication with district nurses immediately on the care system records to include skin integrity issues and any prescribed creams and instructions.
• Senior staff to review MAR charts daily when administering medications to identify any newly prescribed medications/creams that have not been commenced and investigate if needed.
• New MAR charts to be cross referenced with old charts to ensure all relevant information such as allergies are included.
• Risk assessments to be reviewed thoroughly to ensure all previously entered information is correct and reflective.

My analysis

39. Having reviewed the daily care notes, I can see that the Home provided personal and continence care, offered food and fluids, gave Mrs X her medications, and checked her regularly.
40. However, the care provider has accepted some issues with its records about Mrs Y’s medication which is a breach of Regulation 17 to ensure accurate and complete records. In particular there were errors about the creams and noting Mrs Y’s allergy in the MAR plans. This has caused uncertainty to Mrs X about whether Mrs Y was provided with the care she needed.
41. But I am satisfied the care records show the staff at the Home administered a prescribed cream and there was no record of any break in Mrs Y’s skin. Mrs Y was seen by her GP and district nurses who also did not raise concerns about the integrity of Mrs Y’s skin.
42. The care provider has accepted it did not note Mrs Y’s allergy to a medicine on her MAR Chart. Despite it not being on the MAR chart it was recorded elsewhere, and Home had a risk assessment for the issue. The care provider has already apologised to Mrs X for the issues with Mrs Y’s creams and allergy recording which I consider is suitable action for it to take. So, while there was a breach of Regulation 17 causing Mrs X some uncertainty, I do not consider any further investigation will lead to a different outcome or achieve anything more for Mrs X. And I do not recommend any further remedy than the apology already received.
43. We would normally recommend service improvements where there has been fault. But the care provider has already considered the matter and notified of areas of improvements to its record keeping. So, I recommend the care provider explains the action it has taken to improve the care home’s documentation noted as part of learning from the complaint and provides evidence it has been implemented.
44. Mrs X raised concerns about care provided to Mrs Y in the two weeks before she was admitted to hospital which is a possible breach of Regulation 12 to ensure safe care and treatment. But I do not consider there is evidence of fault by the care provider. This is because the care records show the care provider took appropriate action to escalate their medical concerns with Mrs Y’s doctor and the district nurses.
45. Mrs Y was assessed as having a low risk of pressure sores. The care records show staff applied one cream when prescribed and reported no breaks in Mrs Y’s skin integrity. The GP and district nurses did not raise any concerns about Mrs Y’s skin integrity to the care home staff. In addition, hospital staff did not report any concerns on Mrs Y’s admission to hospital. I do not consider any further investigation can achieve anything more for Mrs X on this issue.
46. The care provider confirmed no evidence its care records had been altered and it was likely an issue with the printer or server. I do not consider I can add anything further to the investigation already carried out by the care provider. It is unfortunate, but I cannot say this was fault and it does not change any outcomes for Mrs Y.
47. I have considered very carefully whether the Home did enough to encourage Mrs Y to eat and drink. Mrs Y had capacity to make decisions, was able to make her views known and decline food and drink, which she did on occasions. On the evidence I have seen, Mrs Y food and drink intake was variable, but she maintained a healthy weight and was eating and drinking. There is no evidence she was at high risk of malnutrition and a fluid chart was kept. And I have not seen evidence that Mrs Y’s refusal of food and drink was due to fault by the care provider; meals and drinks were offered, and assistance was given.

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Agreed action

48. Within a month of my final decision the care provider will explain the action it has taken to improve the care home’s documentation noted as part of learning from the complaint and provide evidence it has been implemented.
49. The care provider should provide us with evidence it has complied with the above actions.

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Final decision

50. I am completing my investigation. I have found fault by the care provider as its documentation was not always accurate or complete. The care provider has apologised to Mrs X which is suitable action for it to take.

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Investigator's decision on behalf of the Ombudsman