Summary: The care provider failed to provide a good standard of care and treatment in the short space of time the late Mrs X spent there. In particular the care provider did not monitor Mrs X’s fluid intake properly or take action at the signs of dehydration. The care provider acknowledges the distress caused to Mrs X’s family, has reviewed its practices in terms of fluid monitoring and record-keeping and waived the fees.

The complaint

1. Mrs A (as I shall call her) complains the care provider did not provide good enough personal care for her late mother, failed to provide a soft diet and in particular failed to monitor her fluid intake when she had diarrhoea and sickness. She says as a result her mother was admitted to hospital shortly after her return with dehydration.

Back to top

The Ombudsman’s role and powers

2. 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)
3. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

Back to top

How I considered this complaint

4. I considered all the information provided by Mrs A and by the care provider. I spoke to Mrs A and to the care provider. Both Mrs A and the care provider had an opportunity to comment on a draft of this statement and I considered the comments before I reached a final decision.

Back to top

What I found

Relevant law and guidance

5. 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.
6. Regulation 10 says service users must be treated with dignity and respect.
7. 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, such as: Not providing help and aids so that people can be supported to attend to their continence needs”.
8. 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.”
9. 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.”
10. 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.”

What happened

11. Mrs X went into the care home for a short respite stay on 6 October 2022. Her pre-admission assessment said she needed prompting to eat but said nothing about fluids. She needed daily applications of cream to prevent pressure sores. The notes for 6 October record, “needed prompting with tea and drinks”.
12. By 7 October there was an outbreak of diarrhoea and vomiting in the home. The daily care notes record Mrs X vomiting through the night on 9 October and from then on they record loose bowel movements. On 15 October the records say her “urine was dark in colour” and there was blood in her faeces. By 16 October the notes record Mrs X’s family had visited again and said she had deteriorated since coming into the care home: they questioned whether her medication was being given properly.
13. Mrs X had an open pressure sore on her buttock. The care home’s notes show the care staff regularly contacted the District Nurses who were caring for Mrs X about the wound.
14. On 12 October Mrs X had an unwitnessed fall in her room. The care home records note she was thoroughly checked over by staff but said she had not hurt herself (except for the area around the pressure sore). Care staff put hourly observations in place for 12 hours as a precaution, and also notified her family.
15. Mrs X left the care home on 18 October. Her family called the care home later that night to say Mrs X had been so poorly on her arrival home they had called the doctor. Mrs X was admitted to hospital that evening with dehydration. A note on her file records, “it had been difficult to get her to drink but this is something we were warned about before she arrived and had been asked to prompt her throughout the day which we have been doing constantly.”
16. Mrs X died on 21 October.

The complaint

17. In November Mrs A wrote to the care provider to complain.
18. Mrs A said her mother had only had one shower in the 10 days she was in the home. She said Mrs X had been fully continent before she went into the care home but had not been supported properly with her needs: several times she had been upset and told visitors she had been incontinent because staff did not come in time when she rang her bell. She said Mrs X had not been given enough fluids and had returned home severely dehydrated. The soft diet requested was not provided. She also said there had been confusion over Mrs X’s medication, and the care staff had not protected Mrs X’s pressure sore adequately. She said she had not been told how Mrs X was treated after her fall.
19. The care provider responded. He said proper personal care was documented every day. He said Mrs X had been encouraged to use the en-suite toilet in her room and staff had recorded they regularly checked her and changed her pads. He said all residents were encouraged to eat and drink and would have been placed on a fluids chart if they were not drinking. He said Mrs X had capacity to choose when to eat and drink; fluids were always available to her and staff encouraged her to drink. He said the amount she drank was deemed “acceptable”.
20. The care provider said he had investigated the reports that Mrs X had not been given a pureed or soft diet (Mrs X’s son said he was there when she was given sausage and mash for dinner). The care provider said food like meat and vegetables would have been blended before they were offered to her, and he had not seen any staff reports to the contrary.
21. In response to the complaint that staff did not answer the call buzzer, the care provider acknowledged that at times the bell was not working but staff had increased their observations at those times. On other occasions they had noted that Mrs X “buzzed all day”. He said Mrs X was washed thoroughly every day but usually refused to take a shower.
22. The care provider explained the details of Mrs X’s fall. He noted that care staff had informed the family immediately and there were regular checks documented. He said staff had been aware of Mrs X’s pressure sore and had arranged for the District Nurses to provide a temporary airflow mattress.
23. Finally in response to a complaint about the medication – Mrs A said she believed staff had administered daily some medication which was prescribed for alternate daily use – the care provider said the MAR chart showed the medication had been administered as prescribed, every other day.
24. The care provider said that as a result of the complaint, he had put in place mandatory recording of food and fluid intake for new residents to assess their nutrition and hydration needs. He said he would add nutrition and diet training to the list of mandatory staff training, as well as training in the signs and symptoms of dysphagia. He undertook to require greater detail in the daily progress records so staff had a better picture of a resident’s condition. He concluded however that based on Mrs X’s needs as described in the pre-admission assessment, staff had provided a proper level of personal care, had prompted her to eat and drink as they would any other resident and assisted her with toileting needs.
25. Mrs A remained unhappy and replied to the care provider. She said his findings were at odds with the reports she had heard from her mother’s visitors, who had said how upset Mrs X had been that she had called and buzzed for staff to take her to the toilet but no-one arrived (and so she was incontinent); that they had seen staff bring her plates of food which were not pureed; that visitors to her room had found cups of tea, juice and soup untouched next to Mrs X in her room. She said fluids may have been provided but no-one had encouraged or supported her to drink them.
26. Mrs A complained to the Ombudsman.

Analysis

27. The care provider acknowledges there were times when Mrs X’s call bell was not working. The care records document occasions when Mrs X was not assisted to the toilet in time. Mrs A says Mrs X was continent before she arrived at the care home but the failure of staff to help her promptly caused a loss of dignity which Mrs X was aware of and which caused her distress.
28. The daily care notes only mention Mrs X’s fluid intake on four occasions: on 6 October when she needed prompting to drink; on 7 October when she was noted to have drunk 100ml; on 14 October that she had drunk very little; and on 15 October that she was refusing liquids. The records also show that she had diarrhoea, that her urine was dark and that on 15 October there was blood in her faeces but there is no evidence that staff took any further action to prompt fluids or seek medical advise despite the risks and signs of dehydration. That was fault on the part of the care provider which caused injustice to Mrs X, who was admitted to hospital on 18 October, from her own home, with severe dehydration. It also caused injustice to Mrs X’s family who are left with the uncertainty of not knowing whether the failure to provide appropriate care was a contributory factor in her decline.
29. The records show an adequate level of care for the pressure sore and contact with the District Nurses.
30. The medication administration records show that the medications were being administered appropriately.
31. The care records do not record adequately the care which the provider says was given. Nor is it possible to find from the records I have seen the conclusions the care provider reached in his investigation report. However, I note that the care provider has undertaken improvements in several areas directly related to this complaint: hydration needs training, dysphagia training; and record-keeping.

Back to top

Agreed action

32. Within one month of my final decision the care provider will let me have details of the additional training arranged in the areas he describes in the investigation report;
33. Within one month of my final decision the care provider agrees to acknowledge there were shortcomings in several areas; particular in terms of nutrition and hydration, maintaining Mrs X’s personal dignity in respect of her continence needs, and adequate record-keeping.
34. Following receipt of my draft decision, the care provider has agreed to comply with my recommendations and also waive the fees for Mrs X’s stay.

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

Back to top

Final decision

36. I have completed the investigation. I find that injustice was caused to Mrs X and her family by the actions of the care provider, which the completion of the recommendations at paragraphs 32 – 34 above will remedy.

Back to top

Investigator's decision on behalf of the Ombudsman