Summary: There was fault in the way the care home monitored and recorded Mr D’s nutrition, liquid intake and blood glucose regulation. There was fault in its communications with the family about Mr D’s health and the response to the complaint. The Council has agreed to apologise and pay the family £300.

The complaint

1. Mrs B complains on behalf of her father, Mr D, who has sadly passed away. Mrs B’s complains about Aston Court Care Home, in Sutton Coldfield.
2. Mrs B says the Home failed to provide adequate care and failed to contact medical services early enough. She says the Home did not keep the family informed of the deterioration in Mr D’s health.
3. Mrs B also says there was fault in the complaint responses.

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The Ombudsman’s role and powers

4. 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)
5. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
6. 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

7. I have discussed the complaint with Mrs B and I have considered the information she, the Council and the Home have sent and the relevant law, guidance and policies.

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What I found

8. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards which says:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• The care and treatment must be provided in a safe way for service users. This includes the proper and safe management of medicines (regulation 12).
• The nutritional and hydration needs of the service user must be met. Where a person is assessed as needing a specific diet, this must be provided in line with that assessment (regulation 14).
• Any complaint must be investigated and necessary and appropriate action must be taken in response to any failure identified (regulation 16).
• The Home must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17)

Home’s diabetes policy

10. The Home’s diabetes management policy said that if a resident had blood glucose of 15 mmols or above, they should be tested for ketones.

What happened

11. I have summarised the events and the records insofar as they are relevant to the complaint Mrs B made.
12. Mr D was an older man who had dementia and diabetes. He moved into the Home in November 2021.

Chronology

13. The following paragraphs are a chronology of what happened based on the daily records, the communications with the GP and the emails between Mrs B and the Home.
14. Mr D had a fall on 1 April 2022 and had high glucose levels all day (tested 4 times). The Home contacted the GP and the GP queried whether Mr D may have a urinary tract infection (UTI). It was agreed that that the Home should continue to monitor Mr D’s glucose levels. Later that day the Home rang 111 as Mr D’s glucose level remained high. The 111 service made a referral to the out of hours GP who advised the Home to continue to monitor the blood glucose.
15. Mr D’s glucose levels returned to normal on 2 April 2022 around 17:00 but he tested positive for COVID-19. He had a cough, a runny nose and felt unwell. The Home called Mrs B to let her know.
16. On 3 April 2022, Mr D was not able to walk on his own and used a standing aid to transfer. The Home called 111 and was advised to obtain a urine sample to rule out a urinary tract infection.
17. On 4 April 2022 the care worker found stained sheets and Mr D’s incontinence pad on the floor during the night. Mr D ‘lashed out’ when they tried to assist him. However, later that day he was fine. He had further instances of high blood glucose over the following days and lashed out at staff on one occasion. He needed assistance and was unsteady. He continued to test positive for COVID-19.
18. The notes said Mr D’s case was discussed as part of the GP’s weekly visit to the Home on 6 April 2023, but there is no detail of the discussion. Mrs B said she spoke to the GP on 24 May 2022 and he said he discussed Mr D on 1 April 2022, but did not mention 6 April 2022.
19. Mrs B emailed the Home on 7 April 2022 to ask how Mr D was. The Home replied and said he appeared a little confused, probably because he was in isolation, but ‘he appears okay in himself.’
20. Mr D appeared well over the following days with no major concerns raised.
21. On 12 April 2022, Mr D was described as confused in the morning but was fine by lunchtime and had a settled night.
22. Mrs B emailed the Home on 13 April 2022 to ask how Mr D was. The Home said: ‘As far as I know, your dad is okay. I have not heard anything to make me think otherwise. However I will ask the nurse to call if there are any concerns…’
23. On 14 April 2022, Mr D was described as very unsettled, but he was fine a few hours later. On 15 April 2022 Mr D had trouble walking and seemed very confused. Staff informed the nurse. The plan was to take a urine sample to rule out a UTI and if there was no improvement, to discuss with the GP on their round next week.
24. On 17 April 2022, Mr D presented as confused and was unable to weight bear. On 18 April 2022 Mr D was very confused and angry with staff. He had trouble standing and walking, very shaky with handling his cutlery. He was ‘very pale and generally not himself.’
25. On 19 April 2022, Mr D had a settled night. He went to the dining room for lunch. He tested negative for COVID-19.
26. Mrs B emailed the Home on 19 April 2022 to ask how Mr D was. The Home said: ‘I haven’t heard anything to make me feel concerned about you dad, in fact I saw him in the dining room for lunch. He appears well in himself.’
27. On 20 April 2022, the GP saw Mr D. The Home’s communication record said Mr D was confused, monosyllabic, not walking and still recovering from COVID-19.
28. The GP’s diagnosis was that Mr D had ‘a sudden worsening of confusion on background of dementia and recent COVID infection.’ The GP said Mr D was clinically stable with no acute physical symptoms. He said it was most likely that Mr D had post-infectious delirium. The GP took some blood to test whether there were any reversible causes for the delirium.
29. The Home tried to ring Mrs B’s sister to provide her with an update but she did not answer the phone.
30. On 21 April 2022, Mr D was fine, sitting on his chair. He was described as ‘a bit shaky’ later in the day.
31. He was ‘safe and well’ on 22 April but was then shouting out and unable to weight bear. He was unsettled on 23 April 2022 and raised his voice in the morning, but in the afternoon he was somewhat better. He ate his breakfast and lunch with no problem. He was later described as ‘disorientated’.
32. On 24 April 2022 Mr D was ‘not himself’ and remained ‘quite muddled.’ He needed a lot of encouragement to drink fluids. He was kicking and scratching staff.
33. The nurse took Mr D’s temperature on 25 April 2022 and he had no fever but his blood pressure was high. The nurse retook his blood pressure an hour later and it was still high. The GP rang the nurse and the nurse updated the GP.
34. The GP said the blood test that was taken on 20 April 2022 did not show any significant derangement. He thought that it was still the ongoing delirium but said other possibilities should be considered so this was ‘worth a discussion’ with Mr D’s next of kin.
35. The GP rang Mrs B and explained the situation to her. Mrs B said she wanted Mr D to attend hospital for further examination and the GP agreed this was reasonable. Mr D was taken to hospital later that day.
36. The Home rang Mrs B’s sister and said Mr D had seen a doctor.
37. Sadly, on 27 April 2022 the hospital doctor told Mrs B that Mr D had kidney failure and he was not expected to live beyond a couple of days. Mr D died on 29 April 2022.
38. The GP spoke to Mrs B after Mr D passed away. He said he was surprised to hear that Mr D passed away. He explained the blood results of 20 April 2022 and said there was nothing significantly abnormal in those results. The blood results did not show Mr D suffered from dehydration at that stage. He said that there was significant deterioration on 25 April 2022 which prompted his discussion with the family and the hospital admission.

Mrs B’s complaint

39. Mrs B made 16 complaints to the Council about the care provided by the Home. I have combined some of the complaints where they relate to the same issue or there is duplication. Mrs B said:
• She visited Mr D on 30 March 2022, but was told to wait in the car and come back as they Home was changing his bedding. When she returned, the Home was still changing the bedding so they had to sit in the lounge. It was approaching lunchtime and Mr D said that, if he did not arrive on time in the dining room, he would not receive lunch. Mrs B only spent 30 minutes with Mr D and that was the last time she saw him responsive.
• The Home did not properly monitor Mr D’s food and fluid intake and his blood glucose. The Home did not replace his fluids even though he was incontinent.
• There was a lack of communication from the Home after 2 April 2022 when Mr D tested positive for COVID-19. The family had to initiate all contact.
• The GP visited the Home on 11 and 18 April 2022 for his weekly call. The Home failed to inform the GP that Mr D’s mobility had reduced, he was confused not speaking.
• The Home failed to contact them on 20 April 2022 about Mr D’s condition and the fact that he had been seen by the GP.
• The Home failed to contact the family between 20 and 25 April 2022 about Mr D’s condition.
• The Home failed to see the signs that Mr D’s condition was deteriorating between 20 and 25 April 2022 and did not contact the GP or the emergency services.
• The Home told the family on 25 April 2022 that Mr D had ‘seen’ a doctor. That was not true as the Home spoke to the doctor over the phone.
• The Home failed to provide Mr D with toilet paper which was witnessed three times by Mr D’s daughter.
• The Home frequently lost Mr D’s walking stick which he needed to walk.
• The Home failed to involve the family in the decision making regarding a DNACPR even though this was discussed with the GP on 2 April 2022.

The Home’s response – 27 July 2022

40. The Home responded to the complaint on 27 July 2022 and said:
• Mr D ‘was placed’ on a food and fluid chart on 1 March 2022 because he had lost weight, 4.65 kg, in the last three months. His weight was recorded weekly and his Malnutrition Universal Screening Tool (MUST) score was 1.
• Mr D had loose stools on two occasions, 25 March 2022 and 18 April 2022, but he ate and drank well on those days. There was no record of vomiting. He was encouraged to eat and drink on those days.
• Mr D became incontinent when he had COVID-19. There were ‘inconsistencies with completion’ on the fluid charts and the records on 19 April 2022 were poor. The Home apologised for this.
• The Home apologised for the ‘inconsistent level of completion in our daily fluid and food charts found during our investigation.’ As a result of the complaint, it would hold supervision with the care workers and senior care workers to stress the importance of completing fluid charts. It would also incorporate food diaries on the daily checks of supplementary charts.
• The Home apologised for not contacting Mrs B on 20 April 2022. It had tried to speak to her but had been unsuccessful but the Home acknowledged it should have continued to try.
• The Home apologised for the lack of communication in April 2022 after Mr D was diagnosed with COVID-19. It said that, as a result of the complaint, staff now have to refer to the nursing team, when family ask about the condition of a resident. The Home also reminded staff of the importance of logging residents communications and it had provided additional training on communication with families and outside professionals.
• The Home always saved a meal for a person who was late to go to the dining room.

Council’s response – 30 November 2022

41. Mrs B was not satisfied with the Home’s response to the complaint and escalated her complaint to the Council. The Council responded on 30 November 2022 and said:
• The Home’s records ‘indicate that there were no concerns with your late father’s fluid intakes and that he was eating and drinking well.’ The Home also kept records of Mr D’s bowel movements and his blood glucose levels were monitored twice a day. The Council did not uphold this complaint.
• However the Council also said that, after Mr D was diagnosed with COVID-19, there were ‘some instances of low intake’ of fluids so it partially upheld the complaint that Mr D’s fluids were not managed well, which led to his dehydration when he was admitted to hospital.
• It did not uphold the complaint that the Home should have called emergency services between 20 and 25 April 2022 as ‘no concerns had been identified following consultation with the GP’ and Mr D’s condition was ‘not deemed to have deteriorated until 25 April 2022’. The records showed that Mr D was eating and drinking well during that time. The change in Mr D’s behaviour on 24 April 2022 and the blood test results on 25 April 2022 indicated a deterioration and resulted in calling an ambulance.
• It upheld the complaints about lack of communication which were that the Home:
1. Should have better communicated with the family after Mr D was diagnosed with COVID-19 on 2 April 2022.
2. Should have told the family that Mr D was unwell on 20 April 2022 and that the GP had seen him.
3. Should have updated the family about Mr D’s deteriorating health between 20 and 24 April 2022.
• There was no record of Mrs B’s visit on 30 March 2022 so the Council said its investigation into what happened on that day was inconclusive.
• A meal was saved if a person was late arriving at the dining room, but the Council apologised ‘if your late father may have felt that this did not happen.’ It partially upheld this complaint.
• The Home had not been clear in its communication on 25 April that Mr D had not been seen in person by the GP, but that there had been a telephone conversation so the Council partially upheld this complaint.
• In response to the complaint about the lack of communication with the GP on 11 and 18 April 2022, the Council said the Home had not provided any information about this complaint so the Council upheld the complaint.
• It upheld the complaint that Mr D did not have toilet paper on at least 3 occasions.
• It partially upheld the complaint that Mr D sometimes did not have his walking stick as staff were not always vigilant to ensure he remembered his stick.
• There was no DNACPR document in place so that is the reason why the Home did not raise this with the family.
• The Council said it would ensure that the Home apologised in writing to the family.

Mrs B’s stage 2 complaint – 4 January 2023

42. Mrs B was not satisfied with the Council’s response to her complaint. On 4 January 2023 she sent a letter and 200 pages of evidence to the Council. The evidence included copies of the Home’s records which Mrs B said showed that the Council should uphold her entire complaint.
43. She also said that the Home had still not sent the written apology which the Council had told her would be sent.
44. Mrs B emailed the Council several times in January 2023 as she wanted the Council to confirm that it had received the letter and documents she had sent. She provided evidence that the package been sent by Royal Mail Special Delivery and that a Council officer had signed for receipt of the package on 5 January 2023.
45. The Council did not respond regarding the receipt of the package. However, in its response to the draft decision, the Council said it received the further evidence on 20 June 2023.

The Council’s response – 20 February 2023

46. The Council provided its response to the stage 2 complaint on 20 February 2023. It did not change its position in terms of the complaint except for the following:
• Mrs B had complained that the Home should have alerted medical services between 20 and 25 April 2022 and should have spoken to the family during that time. The Council had previously partially upheld this complaint as it upheld the complaint that the Home should have communicated more with the family during this period. It now said the complaint was not upheld.
• The Council previously said there were concerns around fluid intake after Mr D was diagnosed with COVID-19 and had partially upheld this complaint. Mrs B said that Mr D was diagnosed with dehydration when he was admitted to hospital and later died. However, the Council now said that it could not comment on Mr D’s cause of death and said it had seen evidence of Mr D’s fluid intake so it no longer upheld the complaint.

Home’s records

47. I have read the Home’s records as part of the investigation and the relevant records say the following.

Council’s care plan

48. The Council’s care plan for Mr D said:
• Mr D had type 2 diabetes and it was ‘vital’ that he received meals regularly throughout the day and on time.
49. The Home’s care plan for Mr D said:

Care plan - Nutrition

• Mr D needed a food diary but not a fluid intake/output chart. He was not at risk of malnutrition when he moved into the Home.
• However, the plan also said a food and fluid balance chart should be completed to monitor Mr D’s intake. The Home said in its complaint response that this started on 1 March 2022.
• Mr D was to be weighed monthly or more frequently if he lost weight.
• The Home amended the care plan on 1 March 2022 as Mr D had lost weight so it was decided that he should be weighed weekly from then on.

Care plan - Continence

• Mr D was continent of urine and faeces when he entered the Home.
• His bowel movements had to be monitored daily on the Bristol stool chart (this chart ranks bowel movements from constipation to normal bowel movements to diarrhoea).
• On 15 February 2022 the plan noted that Mr D had been incontinent (urine) on several occasions.
• On 13 March 2022 the plan the plan noted that Mr D had been incontinent (urine and faeces) on several occasions.

Blood glucose

50. The Home kept two records of its daily blood glucose monitoring:
• The Medication Administration Record (MAR) chart where it recorded that it had tested Mr D’s blood glucose.
• A separate record which showed the actual blood glucose reading.
51. I asked the Home to send me the MAR charts from 1 February 2022 until 25 March 2022. I noted the following:
• Mr D’s glucose was tested twice a day every day.
• The Home recorded two glucose readings on every day except for 7 days when only one glucose reading was recorded.
• There were several instances when Mr D’s glucose tested above 15mmol/l or 20mmol/l.
52. The Home has not sent me the records regarding Mr D’s ketone levels. I queried this with the Home. The Home said a different care plan in terms of monitoring ketone levels had been agreed. When there were concerns about sustained high blood glucose levels, the nurses suspected that this was linked to an underlying infection and contacted the GP.

Insulin

53. The Home kept two records of insulin administration:
• The MAR chart where it recorded whether insulin had been administered.
• A separate record of when the injection took place and where (which body part) it had been administered.
54. The Home has not sent me the MAR charts for insulin for the first week of February. I noted the following:
• The MAR charts from 8 February 2022 to 25 April 2022 showed that Mr D’s insulin was administered twice a day every day.
• The Home did not fill in the separate insulin record on 6 occasions during that time.

Food and drink records

55. I asked the Home to send me Mr D’s food and drink intake daily records from 1 February 2022 to 25 April 2022. There should have been records for 83 days.
56. The Home sent me food records for 14 days. The food records related to random dates from February onwards and showed that Mr D often only ate breakfast and lunch in February and March. Some days Mr D ate very little (or very little was recorded). For example, on 10 February 2022 Mr D ate two slices of toast and on 27 February 2022 he ate four slices of toast and some biscuits.
57. However, the Home did keep a daily record of food intake between 22 April to 25 April 2022 and these showed that Mr D ate three meals a day during that time except on 23 April 2022 when he did not eat his evening meal.
58. The Home did not send me any fluid records from 1 February 2022 to 1 April 2022. It sent me fluid records from 2 April to 25 April 2022, but the records for 7,10,16, 17 April were missing. I noted the following:
• 5 April 2022 - Mr D drank 200 ml.
• 6 April 2022 - 350 ml.
• 12 April 2022 – 300 ml.
• 20 April – 900 ml.
• 21 April – 1050 ml.
• 22 April – 900 ml
• 23 April – 950 ml.
• 24 April – 1000 ml.
• 25 April – 400 ml. The chart noted that Mr D was offered drinks 7 times during the day, totalling 1200 ml, but he refused most drinks.

Bowel movements

59. The Home kept a Bristol Stool Recording Form. The chart noted that Mr D was self-toileting (not using incontinence pads) until 13 April 2022. From 18 April 2022, Mr D used incontinence pads. I have checked the dates from 20 to 25 April 2022. Mr D had mild diarrhoea once on 22 April. He did not have diarrhoea on 23 and 24 April and had mild diarrhoea four times on 25 April 2022.

Weight

60. Mr D weighed 95 kg when he entered the Home in November 2021 and he weighed 85.9 kg the last time he was weighed on 12 April 2022. His BMI went from 31 (obese) to 28 (overweight).

Analysis

Nutrition monitoring

61. There was fault in the Home’s recording of Mr D’s food intake. The care plan was slightly contradictory as it appeared that Mr D needed a food diary from the time he moved in as it was included in the original care plan. But a food diary was not filled in.
62. The care plan was then amended to say that Mr D should have a food chart to monitor daily intake. The Home said that this change was made on 1 March 2022 after it noticed that Mr D had lost a lot of weight. However, even after 1 March 2022, the Home did not fill in the food charts regularly. The Home sent me 5 charts for February, 5 charts for March and 4 charts for April 2022. That was clearly insufficient and fault.
63. In addition, I was concerned about the record keeping on those days when the Home had filled in the charts. For example, on 10 February 2022 the record said Mr D only ate two slices of toast. Clearly the Home was either not properly recording Mr D’s food intake or was not feeding him enough food. Either way, there was fault.

Fluid monitoring

64. There was fault in the Home’s recording of Mr D’s fluid intake. The initial care plan said Mr D did not need a fluid chart but this was later revised. The date of the revision is not stated but the Home said it was changed on 1 March 2022. The Home has not sent me any fluid intake records for March 2022 and the records were missing for five days in April 2022. So this was fault.
65. Also, as with the food recording, there were concerns that the Home was not properly recording the fluid intake on those days when records were kept. For example, there was one day when Mr D’s fluid intake was only 200 mls.

Diabetes

66. I asked the Home to send me the MAR charts from 1 February 2022 onwards. In its initial response the Home sent me the MAR charts from 21 March 2022 only. I asked the Home to send me the missing charts which it did although I am still missing the MAR chart relating to the insulin administration between 1 and 7 February 2022.
67. The records that I have seen showed that the Home checked Mr D’s blood glucose level twice a day and administered his insulin twice a day. However, there were times when the Home failed to record the actual blood glucose level and the site of the insulin injection. This was fault.
68. The Home also did not check Mr D’s ketone levels when his blood glucose levels were high in line with its policy. The Home says it a adopted a different care plan in terms of ketone monitoring. The Home should have recorded this in the care plan and failed to do so. This was fault. Also, it is not clear from the documents who agreed to the change in the care plan and this should have also been recorded.

Contacting medical services

69. Mrs B complained that the Home should have contacted the GP or emergency medical services earlier.
70. It is not in dispute that Mr D’s presentation changed after his COVID-19 diagnosis. He became less mobile, more confused and he became more incontinent. The records showed this. However, the question is whether these changes were so concerning that there was fault in the Home’s decision not to involve medical services earlier.
71. That is a difficult question to answer. I have done so by considering what the medical response was when the Home did involve them. I note the GP saw Mr D on 20 April 2022. The GP said Mr D was clinically stable and had no acute physical symptoms. He thought Mr D may be suffering from post-infection delirium and ordered a blood test. Therefore, at this stage, Mr D’s presentation did not indicate that there was a medical concern that needed urgent attention.
72. In the following days, Mr D ate and drank reasonably well, but he continued to show signs of confusion and decreased mobility particularly from 23 April 2022 onwards.
73. When the nurse spoke to the GP on 25 April 2022, the main concerns were that Mr D had high blood pressure and that his symptoms, particularly his confusion, had not improved. He had mild diarrhoea and was refusing fluids. However, even at this stage, the decision to take Mr D to the hospital was not taken by the GP but by the family. This suggests that Mr D’s presentation did not indicate that an emergency admission was needed. I also note that the GP expressed surprise when he found out that Mr D had passed away in hospital. This again suggested that Mr D’s presentation did not give cause to immediate alarm.
74. I have also investigated Mrs B’s complaint that Home had a conversation with 111 about the DNACPR on 2 April 2022 and did not inform her of this.
75. My reading of the conversation between the Home and 111 was that the Home wanted some clarification of what the next steps were, in terms of the DNACPR if Mr D deteriorated. I agree it may have been helpful to let Mrs B know about this, but I would not say there was fault. In any event, the DNACPR was never needed so no injustice was suffered.

Communication with the family

76. There were significant faults in the Home’s communication with Mr D’s family after Mr D was diagnosed with COVID-19. I note that the Home did not initiate any contact with the family after its initial call on 2 April 2022 until 20 April 2022. As the family could not visit Mr D and as he was ill with COVID-19 I would have expected the Home to contact the family regularly.
77. Also, when the family rang the Home to obtain information, the Home did not check Mr D's records or speak to the people providing care to Mr D, before it provided the family with updates. This meant that the information the Home gave to the family was not correct and not up to date which was further fault.
78. I also agree the Home should have updated the family after the GP saw Mr D on 20 April 2022. I accept the Home tried to ring Mrs B’s sister but she did not answer. The Home should have tried to ring Mrs B or tried to ring the sister again later.
79. There was then further fault as the Home failed to contact Mrs B in the days between 20 and 25 April 2022. The Home knew there were concerns from 20 April 2022 onwards and had involved the GP. Therefore, it was even more important that the Home kept Mrs B informed of the situation, but the Home failed to do so.

Other complaints

80. Unfortunately, there is no further information in the records relating to Mrs B’s complaint about events on 30 March 2022 so there is unfortunately nothing further the Ombudsman can add.
81. The Council has already upheld the complaint that the Home failed to provide Mr D with toilet paper on three occasions and that it frequently lost Mr D’s walking stick. I agree that was fault.

Responses to the complaint

82. Mrs B said the Home had still not provided a written apology which had been promised in the Council’s response on 30 November 2022. I uphold that complaint.
83. I agree there was some fault in the Home and Council’s response to the complaint. The Council’s initial response contained inaccuracies and sometimes contradicted itself, particularly related to the fluid and nutrition intake. The Council said were no concerns about Mr D’s fluid intakes and he was eating and drinking well, when this was not a reflection of what was recorded, as noted above. I accept that the underlying problem was that the Council relied upon the information and complaint response provided by the Home at the time which was not accurate.
84. Mrs B then raised these factual inaccuracies and other concerns about the complaint to the Council and sent the Council documents as further evidence of her complaint. The Council has not said what happened to those documents Mrs B sent but I presume they were lost internally. This meant the Council did not consider them as part of its stage 2 response which meant the inaccuracies were not addressed.

Injustice and remedy

85. In terms of the nutrition and liquid intake and diabetes recording, I appreciate that these faults related mostly to the recording of actions rather than the actions themselves. Nevertheless, these faults were concerning. Keeping good records was vital for monitoring. If the Home did not record, for example, how much food or drink Mr D had in a particular day, then it was unable to monitor whether he was eating or drinking enough.
86. This would be concerning for any person but it was particularly concerning as Mr D had diabetes and needed regular meals at regular times. He was losing a lot of weight in a relatively short time and this should have been properly monitored. Similarly, I note that the Home took regular readings of Mr D’s glucose, but they should have always been recorded to establish any trends.
87. The injustice by the Home’s failure to communicate was great. It meant that Mrs B was under the mistaken impression that Mr D was doing well, despite having COVID-19. It was a great shock to her when she found out, on 25 April 2022, that Mr D’s health had deteriorated. This lack of information and incorrect information clearly added to Mrs B’s distress, even more so after Mr D passed away in hospital. This could have been avoided by more frequent and more accurate information.
88. The Council then lost the evidence Mrs B sent in her stage 2 complaint which meant the evidence was not considered in its response which added to Mrs B’s distress.
89. Sadly, Mr D has passed away so any injustice to him cannot be remedied. However, I do not underestimate the distress that the fault caused Mrs B.
90. In cases such as this one, where the fault did not cause a direct financial loss, the Ombudsman can recommend a small symbolic financial sum to reflect that a person has suffered distress. I recommend the Council pays Mrs B £300.
91. I note that the Home has already made the following service improvements because of Mrs B’s complaint:
• It held supervision with the care staff to stress the importance of completing daily charts.
• Any staff member who is communicating with the family of a resident about the condition of the resident, will have to refer to the nursing team for a response.
• It has reminded staff of the importance of logging all resident communication.
• Additional training is being provided to staff regarding communication with families and professionals and record keeping.
• It has reminded its clinical team of the importance of regular and proactive communication with family members.
92. I will therefore not recommend any additional service improvements. However, I will share this decision under the Ombudsman’s agreement with the CQC. The CQC is best placed to consider if there are any remaining concerns.

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Agreed action

93. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the service of the Home, I have made recommendations to the Council.
94. The Council has agreed to take the following actions within one month of the final decision. It will:
• Apologise in writing to Mrs B for the fault.
• Pay Mrs B £300.

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Final decision

95. I have completed my investigation and found fault by the Council. The Council has agreed the remedy to address the injustice.

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Investigator's decision on behalf of the Ombudsman