Summary: Ms X complains the Care Provider failed to provide acceptable standards of care to her mother, and breached COVID-19 regulations. Ms X also complains about the Care Provider’s investigation into her mother’s fall and her death. The Ombudsman finds fault with the Care Provider for being unable to evidence how it has met the CQC fundamental standards of care, and for failing to provide some elements of care. The Ombudsman also finds fault with the Care Provider for failing to properly investigate the complaint. The Care Provider has agreed to make a payment for uncertainty and distress to Ms X, and implement service improvements.

The complaint

1. Ms X complains the Care Provider did not provide reasonable care to her mother, Mrs Y, during her stay at the care home. Ms X complains staff failed to

• maintain her mother’s hygiene
• support her mother to be mobile and exercise
• provide stimulation and encouragement for physical and mental activities
• support her mother while eating
• follow COVID-19 regulations
• update her on her mother’s health
• update her about health professionals, medical appointments, daily activities and accidents.

2. Ms X also complains about the Care Providers handling of her mother’s fall and the actions following her death.

Back to top

The Ombudsman’s role and powers

3. We investigate complaints about adult social Care Providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social Care Provider’s actions have caused 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)

Back to top

How I considered this complaint

6. I considered Ms X’s complaint and information she provided. I also considered information from the Care Provider.
7. I considered comments from Ms X and the Care Provider on a draft of my decision.
8. The Care Quality Commission (CQC) is an independent regulator of all health and care services in England. Under an information sharing agreement between the Local Government and Social Care Ombudsman and CQC, we will share this decision with CQC.

Back to top

What I found

Legislation and guidance

Fundamental Standards of Care

9. 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.
10. Regulation 10 says service users must be treated with dignity and respect.
11. Regulation 13 says “Providers and staff must take all reasonable steps to make sure that people who use services are not subjected to any form of degradation or treated in a manner that may reasonably be viewed as degrading.”
12. Regulation 14 says the nutrition and hydration needs of service users must be met. It says, “Nutrition and hydration needs should be regularly reviewed during the course of care and treatment and any changes in people’s needs should be responded to in good time.”
13. Regulation 17 says, “Records relating to the care and treatment of each person using the service must be kept and be fit for purpose. Fit for purpose means they must: Be complete, legible, indelible, accurate and up to date, with no undue delays in adding and filing information, as far as is reasonable.”
14. In February 2023 the Ombudsman published guidance for Care Providers on good record keeping. We said, “We are likely to find a Care Provider at fault where records are illegible or have clearly been changed after the event, where they are inadequate for their purpose, or where they omit essential information or include misleading information.

Back to top

What happened

15. Mrs Y became a resident of the Care Provider in November 2021.
16. The Care Provider carried out reviews of Mrs Y’s health throughout her stay, which identified that she was at risk of falls, and that she would need support for certain daily tasks. It also noted that she had capacity to make decisions and commented on her preferences for daily tasks.
17. Mrs Y had several falls while under the care of the Care Provider. The Care Provider recorded each one and documented whether Mrs Y had been injured. It recorded that it notified Mrs Y’s family and where it had sought medical advice, this had been followed. It carried out a risk assessment and installed bed rails to prevent falls at night.
18. Mrs Y had a further fall in October 2022. A few hours after the fall, Mrs Y died. The Care Provider contacted the police and followed its unexpected death policy. It also liaised with Ms X about Mrs Y’s belongings.
19. In November 2022, Ms X complained to the care home. In her complaint, she said;

• Mrs Y should have been receiving regular exercise but there was not enough staff to provide this.
• The Care Provider did not adhere to COVID-19 lockdown procedures and prevented exercise and mobility as Mrs Y was kept in her room for long periods of time.
• Mrs Y was not regularly showered, and her hygiene was not monitored.
• Staff had been aggressive to Mrs Y when she was on the phone.
• Staff had given Mrs Y alcohol.
• Staff did not support Mrs Y with her food by cutting it up and clearing old food away.
• Staff did not suitably handle the events following Mrs Y’s death. Staff were not available and prevented Mrs Y’s belongings being recovered.
• Mrs Y had fallen shortly before her death and Ms X felt the fall could have contributed and wanted the Care Provider to investigate this and provide a written outcome.
• The Care Provider had failed to regularly contact Ms X about Mrs Y’s general health and health monitoring.

20. The Care Provider responded to Ms X’s complaint in January 2023. In the response it said

• The pandemic put great strain on the Care Provider and it did everything it could to prevent cross infection. At times this meant residents had to uphold social distancing and spend long periods of time in their rooms.
• Staff washed Mrs Y daily and showered her weekly.
• Mrs Y did not like staff cutting up her food.
• Staff were sometimes too busy to clear dishes immediately, but if this had been bought to their attention, they would have done it.
• The raised voices heard on the phone were out of concern for the risk of Mrs Y falling.
• It should not have given Mrs Y the brandy.
• Staff gave Mrs Y the choice of whether to get dressed and where to sit.
• Staff recorded the fall shortly before Mrs Y’s death and called the police. Police directed staff to carry on with their duties. Access to valuables is limited to certain members of staff, and this meant Mrs Y’s belongings could only be recovered when those staff were available.
• The Care Provider maintained regular contact with all professionals for Mrs Y, and it recorded all care on the system.

21. Ms X remained unhappy with the Care Providers response and bought her complaint to the Ombudsman.

Analysis

Hygiene

22. Part of Ms X’s complaint is the Care Provider failed to preserve Mrs Y’s hygiene.
23. In the complaint response, the Care Provider told Ms X that staff washed Mrs Y daily, and showered her weekly.
24. I asked the Care Provider for the records for Mrs Y’s hygiene. It provided me with her daily records which showed that on several occasions, Mrs Y was not washed daily, and there were periods of time longer than a week where she did not shower. This was fault causing Mrs Y injustice.
25. The Care Provider has not been able to evidence how it preserved Mrs Y’s hygiene through weekly showering, or that she was washed daily. The Care Provider has not been able to meet the CQC’s fundamental standards in this regard. As Mrs Y has died I cannot remedy this injustice to her, however I accept that Ms X has been caused distress about whether Mrs Y received adequate care for her hygiene.

Food

26. Part of Ms X’s complaint is the care home did not support Mrs Y to eat. This included not cutting up her food or clearing old food away.
27. The Care Provider said Mrs Y did not like her food cut up, and sometimes staff couldn’t clear old dishes quickly.
28. The Care Providers assessment of Mrs Y when she arrived at the care home took note that she liked to make independent decisions about her food. However, the care records also show that Mrs Y was consistently losing weight while with the Care Provider. I would have expected the Care Provider to show it recognised this and had discussions with Mrs Y, her family and involved health professionals about how to support her with her eating.
29. Mrs Y was losing weight despite her social mobility being restricted and she could not move around as normal. This should have prompted further consideration from the Care Provider. The CQC fundamental standards set out that food and hydration should be regularly reviewed and changes should be responded to. I have not seen evidence the Care Provider did this. Failure to do so was fault by the Care Provider.
30. As Mrs Y has died I cannot provider her a remedy for this injustice. However, I accept that Ms X has been caused distress and uncertainty about whether her mother received suitable care in this regard.

Mobility, exercise and COVID-19 regulations

31. Part of Ms X’s complaint is the Care Provider did not support Mrs Y with exercise and mobility.
32. The Care Provider has accepted that it restricted Mrs Y’s mobility and social interaction due to the COVID-19 restrictions. It recognised that at times, Mrs Y was kept in her room for long periods of time. I accept Ms X’s concerns that this meant Mrs Y’s mobility was limited and she did not get the care that was agreed.
33. On 17 May 2021 the Government announced care home residents would be able to have up to five named visitors, up from the previous two visitors. Self-isolation for residents would no longer be required following visits they made to GPs, dentists and day centres.
34. Guidance stated residents with COVID-19, whether symptomatic or asymptomatic can safely be cared for in a care home if the guidance is followed. Normal duties and powers under the Mental Capacity Act 2005 apply but decision makers can consider a proportionate approach to such assessments to enable timely discharge.
35. On 14 June 2021 the Government announced a further relaxation, with effect from 21 June 2021, with care home residents now able to leave the home to spend time away with family and friends. People admitted to a care home from the community would no longer have to self-isolate for 14 days on arrival having had tests before admission, on the day of admission and seven days after admission.
36. The guidance also said Care homes should follow social distancing measures and where possible shielding guidance. These measures were subject to review and amendment throughout the COVID-19 outbreak.
37. The Care Providers complaint response recognises that at times during enforced lockdowns, residents were confined to their rooms for long periods. However, on reviewing the guidance in place while Mrs Y was a resident, I have found there were no enforced lockdowns, and the social distancing measures had been relaxed. I accept that at times, when residents had COVID-19 there may have been need to confine them to their rooms, and where there may have been multiple residents with COVID-19 the Care Provider may have had to have its own lockdown. However, I do not accept that this should have been applicable to most residents during the time Mrs Y was a resident and the Care Provider has not provided evidence to show otherwise.
38. I cannot provide a remedy Mrs Y for this injustice, however I accept that Ms X was caused distress knowing her mother may have not received the care agreed.

Communication

39. Part of Ms X’s complaint is the Care Provider did not regularly communicate with her about Mrs Y’s condition. Ms X felt the Care Provider should have regularly updated her about health professionals, appointments, daily activities, and accidents.
40. The Care Provider commented in the complaint response that it had had continuing communications with professionals about Mrs Y, and it had monitored all of her health conditions and day to day activities. The complaint response did not address Ms X’s complaint the Care Provider had failed to communicate with her and the rest of Mrs Y’s family about these issues.
41. The Care Provider has not been able to show that it did communicate with Ms X about Mrs Y on a regular basis. However, I have not seen any communication from Ms X that went unanswered when Mrs Y was a resident. On balance, it is likely that Ms X felt the Care Provider should give updates about Mrs Y’s health, when in reality, this was not something the Care Provider could do regularly. However, questions and concerns about Mrs Y would have been answered or addressed had they been asked.
42. I am satisfied the Care Provider kept detailed records of the professional input it sought for Mrs Y, and of any concerns for Mrs Y. The records of professional input were provided to Ms X as part of the complaint response.
43. I find fault in the Care Provider not fully addressing Ms X’s concerns in the complaint response. I do not find fault in how the Care Provider communicated with Ms X before this.

Circumstances of death and events that followed

44. Part of Ms X’s complaint is the Care Provider failed to properly investigate Mrs Y’s fall and death.
45. The care records show that Ms X had multiple falls while she was in the care of the Care Provider. Each of these was recorded, and the Care Provider also conducted a risk assessment which looked at the options for helping avoid further falls. The Care Provider recorded that Mrs Y was a high risk for falls and agreed that bed rails were suitable to stop falls at night. It also identified that she needed support for certain daily activities to prevent falls.
46. The care records show that Mrs Y had a fall a few hours before she died. The care records say she was fine after the fall and had no injuries.
47. When Mrs Y died, because her death was unexpected and she had recently been checked by staff, the Care Provider followed its policy for unexplained deaths. This included alerting the police and following the recommendations from the police.
48. It is not possible to decide if Mrs Y’s fall contributed to her death. That is the role of the coroner, and as Ms X refused an autopsy, it is unlikely to ever be established.
49. However, I find no fault in the Care Providers handling of the fall and unexpected death. The Care Provider recorded the fall, checked Mrs Y and then followed its policy for unexpected deaths.
50. The previous assessment and records for Mrs Y identified that she was at high risk of falls, and also identified the areas she needed support and aids that might help prevent the falls. The Care Provider has suitably displayed that it took measures to prevent falls. Therefore, I find no fault in this regard.
51. I appreciate that Ms X feels the Care Provider could have made things easier following the death and later with returning possessions. The Care Providers told Ms X staff followed the police guidance at the time and that only certain staff can access valuable belongings which resulted in the delay of returning these to the family. I find no fault with the Council for this part of the complaint.

Back to top

Agreed action

52. Within 4 weeks the Care Provider has agreed to

• Write to Miss X and apologise for the fault identified
• Pay Miss X £350 in recognition of the distress and uncertainty caused
• Review how it records residents’ hygiene and care needs for this area to ensure consistent recording.
• Review how it checks changes in food, fluid and weight to ensure that care needs are adjusted for changes.

53. The Care Provider should provide us with evidence it has complied with the above actions.

Back to top

Final decision

54. I have now completed my investigation. I find fault with the Care Provider for failing to evidence how it met the CQC fundamental standards of care. I also intend to find fault with the Care Provider for its failure to provide some elements of care and for failing to fully investigate Ms X’s complaint. I have made recommendations the organisation has agreed to carry out.

Back to top

Investigator's decision on behalf of the Ombudsman