Summary: Care provided to Mrs X during a residential respite stay was below an acceptable standard. We have made recommendations to address this.

The complaint

1. Mr X complains about the care provided to his late wife during her stay at Abbotsleigh Mews Residential Care Home.

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The Ombudsman’s role and powers

2. 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)
3. 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

4. I have:

• considered the complaint and discussed it with Mr X;
• considered the correspondence between Mr X and the Care Provider, including the Care Provider’s response to the complaint;
• considered the safeguarding documents completed by the relevant Council;
• considered relevant legislation;
• offered Mr X and the Care Provider the opportunity to comment on an draft of this document, and considered the comments made.

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What I found

Relevant legislation

5. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall. These include:

• 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.
• 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.
• Regulation 17 of the 2014 Regulations requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.

6. Providers must do all that is reasonably practicable to mitigate risks. Incidents that affect the health, safety and welfare of people using services must be reported internally and to relevant external authorities.
7. Section 42 of the Care Act 2014 says a safeguarding duty applies where an adult:

• has needs for care and support;
• is experiencing, or at risk of, abuse or neglect; and
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.

8. If the section 42 threshold is met, then the Council must make enquiries or cause others to do so. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect and if so, by whom.

Key facts

9. Mrs X was in her seventies. She had a diagnosis of Alzheimer’s disease.
10. She went into the care home on 16 August 2022. On admission she was able to feed herself and drink independently. She was reported to recognise significant family members.
11. The daily care records show Mrs X to be often agitated and on occasions distressed during her stay. She slept very little and tended to cat-nap during the day.
12. On 18 August 2022, the care home contacted Mrs X’s GP to discuss her distressed state. The GP said Mrs X had been prescribed an anti-depressant on 16 August 2022. The care home contacted the previous care home Mrs X had been resident in to ask if it had the medication, it said not, so the care home contacted the local pharmacy, who confirmed it had the medication ready to deliver. The pharmacy was not aware Mrs X had moved homes. The records show the medication was delivered the following day and administered as per the instructions.
13. The daily care records document when Mrs X was offered food and fluid, and if it was accepted or refused. Care staff recorded the amount of fluid offered and the amount taken. They also recorded when Mrs X passed and when her Mrs X’s incontinence pad was wet. All other information pertaining to Mrs X’s daily routine/care was also recorded.
14. There was no stand-alone fluid balance chart.
15. The records show that between 16 August 2022 and 18 August 2022 Mrs X accepted small but regular amounts of fluid. On 19 August 2022 she declined all offers of food and fluid. On 20 August, she ate very little and drank only 100mls of fluid. On 21 August she accepted very small amounts of fluid throughout the day. On 22 August, Mrs X declined all offers of fluid.
16. On 20 August 2022 Mr X and his daughter visited Mrs X and both reported their concern that Mrs X was ‘drugged up’. The records confirm this conversation. The records show Mrs X was helped to her room, that she walked with assistance from her daughter.
17. On 22 August 2022 a DOLS assessor visited Mrs X and informed her family that he thought Mrs X was dehydrated and that she needed to go to hospital. There are no records to show he informed the care home.
18. Mrs X’s family insisted the care home call an ambulance. Mr X says it refused, so Mr X’s daughter made the call. An ambulance arrived and Mrs X was transported to hospital. On admission she was found to be severely dehydrated. Mrs X was placed on an intravenous drip which remined in situ for 48 hours. Mrs X was in hospital 16 days.
19. Mrs X was discharged from hospital to a different care home, where she stayed until she sadly passed away on 28 December 2022. Mr X has no complaint about this care home.
20. A safeguarding referral was made to the local Council in respect of the care Mrs X received at Abbotsleigh Mews Care Home, following which a Section 42 safeguarding investigation was subsequently completed. I have had sight of the safeguarding documentation. The investigation upheld the allegation that Mrs X was dehydrated. It found the allegation that Mrs X was ‘drugged’ to be inconclusive. Allegations that Mrs X was found slumped in a chair, and that carers were unsupportive and rude were also found to be inconclusive.
21. Mr X submitted a formal complaint to the Care Provider on 27 August 2022. He received an initial response on 2 November 2022, which he was dissatisfied with. He contacted the Care Provider to express his dissatisfaction on 7 November 2022, and he received a final complaint response on 4 January 2023. I have had sight of this letter. The letter is detailed and responds to all the issues raised. In respect of Mrs X’s fluid intake and subsequent dehydration, the author of the letter confirmed that care staff had no concerns about Mrs X’s condition at the time and therefore saw no reason to seek medical advice. However, the author went onto say, “I would like to assure you that this has been taken into account and that as part of the lessons learned from this complaint investigation staff will be provided with refresher training around Nutrition and Hydration as well as revisiting the Hydration Policy which provides guidance around the signs and symptoms that could indicate the risk of dehydration… I am sorry that there are differences in what is being said about the timeline of events on this date and would like to assure you that staff have been reminded about the importance of record keeping and documenting events and conversations in the care records at the time or soon as possible afterwards. Staff have also been reminded to listen and act upon relatives concerns and to seek medical advice if this is being requested linked to changes in the resident’s condition that they are seeing”. The author also acknowledged some fault in relation to record keeping, that it had found “…differences in what is being said about the timeline of events on this date and would like to assure you that staff have been reminded about the importance of record keeping and documenting events and conversations in the care records at the time or soon as possible afterwards”.
22. Mr X is dissatisfied with the response. He believes it does not accurately represent some of the events/conversation he had with care staff and that it provides no real explanation for the rapid deterioration in Mrs X condition.
23. In its response to enquiries made by this office, the Care Provider says it had no concerns about Mrs X’s health or had reason to believe she was dehydrated. However, it says since Mr X’s complaint “Supervisions have been had in regards to Signs and Symptoms of Dehydration – all care staff have completed this with information attached for them to keep”.

Analysis

24. People are entitled to safe, effective and high-quality care. In Mrs X’s case, the Care Provider fell short of these standards and failed to reach the Care Quality Commission’s fundamental standards particularly in terms of person-centred care.
25. I consider there is evidence to find that Mrs X did not receive enough hydration in the days before her admission to hospital. The Care Provider did not adequately record her levels of fluid intake. It should have completed a stand-alone fluid balance chart. Had it done so, it may have been alerted to a very low fluid intake. That was a fault, suggesting a breach of the CQC fundamental standards.
26. The Care Provider should have liaised with Mrs X’s GP for advice about hydration. There is no evidence it did so which is a failure to act in line with Regulation 12 and fault.
27. It is of concern to the Ombudsman, that in its response to our enquiries, the Care Provider continues to assert that there was no evidence to suggest Mrs X was dehydrated, when in fact there was, it was clear to the DOLS assessor, Mrs X’s family and the attending ambulance crew. Information within its own daily care records clearly shows Mrs X’s fluid intake was very low and not sufficient for adequate hydration.
28. The Care Provider upheld Mr X’s complaint about the accuracy of records. It was required by Regulation 17 to keep accurate, complete and contemporaneous records of care delivered. It did not do so and was at fault.
29. It is also fault for the Care Provider not to have picked up on these discrepancies in its records when Mr X raised his concerns. Regardless of the safeguarding investigation the Care Provider had a duty to consider the issues when Mr X first raised a complaint. It needed to scrutinise its own records of Mrs X’s fluid intake in the lead up to her hospital admission. It had to do this to conform with its requirement to take all concerns and complaints seriously and be candid in its consideration of such concerns. It failed to do so, which is fault.
30. I have seen no evidence which shows Mrs X was ‘drugged’. Records show medication was administered as per the prescribed instructions.
31. The Care Provider’s faults caused injustice to Mrs X. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of, for example, the impact of poor care that person might have received while they were alive. This is because the person who received the poor care cannot benefit from such a payment. However, if we consider the person who has complained to us has been adversely affected by seeing the impact of that poor care on their relative, we may recommend a symbolic payment to them as a remedy for their own distress.
32. This situation has caused Mr X significant distress. Although this cannot be remedied by a payment, I consider the symbolic amount to Mr X of £500 to be appropriate in acknowledgment of his distress, and the time and trouble he has been put to pursuing the matter with the Care Provider and this office.

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Agreed action

33. The Care Provider should within four weeks of the final decision:

• provide an unreserved written apology to Mr X for the failings set out above;
• provide a payment to Mr X of £500 to reflect his injustice in the form of distress;
• waive outstanding care fees;
• provide a copy of the final decision to the council’s safeguarding team.

34. In addition, within three months:

• write to us and explain what lessons it has learnt from this investigation and what changes it has made to its procedures. I will not be prescriptive about exactly what changes the Care Provider needs to make but I suggest this encompasses;
• The introduction or a review of a nutrition and hydration policy to ensure that users of its services are receiving adequate hydration and it is adequately monitoring this.

35. The Care Provider should provide this office with evidence it has complied with the above actions.

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Final decision

36. Care provided to Mrs X during a residential respite stay was below an acceptable standard.
37. The above recommendations are a suitable way to settle the complaint.
38. It is on this basis; the complaint will be closed.
39. Under the terms of our Memorandum of Understanding I intend to send a copy of the final decision statement to the Care Quality Commission.

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Investigator's decision on behalf of the Ombudsman