The Ombudsman's final decision:
Summary: Mr Y complains about the Care Provider’s failure to seek timely medical treatment for his wife, Mrs Y, when she had a period of illness in November 2022. We find some delay by the Care Provider which was, in part, caused by poor written records and a lack of handover between staff members. We also find the Care Provider provided conflicting information about Mrs Y’s need for hourly checks through the night. The Care Provider has agreed to complete the actions listed at the end of this statement.
- Mr Y complains about the failure of ‘Oldbury Grange Nursing Home’ to seek prompt medical intervention when Mrs Y became unwell in November 2022.
- Mr Y says the failures were caused by a lack of adequate staff handover, failure to make written records and a lack of knowledge amongst staff about the options in place to seek medical assistance from a ‘Rapid Response’ team.
- Mr Y also complains the Care Provider altered Mrs Y’s care plan without consultation or justification. He says that staff sometimes fail to adhere to the care plan.
- Mr Y also complains the Care Provider failed to take appropriate action when Mrs Y’s intake of food and fluid declined.
The Ombudsman’s role and powers
- We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (Local Government Act 1974, section 26A or 34C,)
- 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)
- If an adult social Care Provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
- 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)
How I considered this complaint
- During my investigation I discussed the complaint with Mr Y and considered the information he provided.
- I made enquiries of the Care Provider and considered its response. I also consulted the relevant law, guidance and policies which I have referred to in this statement.
- Mr Y and the Care Provider had an opportunity to comment on my draft decision. I considered their comments before making a final decision.
- 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.
What I found
What should have happened
Relevant law and guidance
- 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. The regulations relevant to this complaint are:
- Regulation 9 “Person Centred Care” says care providers should, “enable and support relevant people to make or participate in making, decisions relating to the service user's care or treatment to the maximum extent possible”.
- Regulation 12 aims to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Care providers must assess the risks to people's health and safety during any care or treatment and act to mitigate risks.
- Regulation 17 says care providers should, “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.”
The Care Provider’s policies
- The policy ‘Early warning signs of a deteriorating resident’ sets out the following key principles:
- Staff will recognise and escalate early deterioration of a resident’s health to minimise referrals to secondary care and reduce further complications.
- Staff will have the appropriate knowledge and training to recognise any changing needs and early signs of health deterioration in residents to ensure they receive timely medical intervention.
- Staff to record any observations using the NEWS system (National Early Warning Score) and SABARD (Situation Background Assessment Recommendation and Decision).
- For urgent concerns, the staff member or their team leader can call NHS 111 for advice. When a resident is unwell, but not in immediate danger, the staff member will escalate as per the home’s procedures.
- The Care Provider’s ‘Meeting Nutrition and Hydration Needs’ policy sets out the following key principles:
- When staff identify concerns about a resident’s nutrition or hydration, through an assessment or review of the Malnutrition Universal Screening Tool [MUST], they will trigger a GP referral.
- Concerns will be followed up with continued monitoring and reporting.
- Nutrition and hydration will be reviewed in line with any risks identified in the MUST. Where this includes weighing the person, the results will be recorded in care notes and major changes notified to the GP or dietician.
Summary of key background events
- Mrs Y resides in Oldbury Grange Nursing Home (‘the home’). Prior to October 2022, Mrs Y received hourly checks throughout the night as confirmed by her care plan which said: “[Mrs Y] to be checked hourly during the night to ensure she is safe and comfortable. Hourly checks to be evidenced by the sighting chart”. These checks take place for those who have a higher level of support or need greater monitoring.
- The home reviewed the needs of all residents in late 2022. It identified that many residents were receiving hourly checks throughout the night despite there being no clinical need. The home removed hourly sighting checks for several residents, including Mrs Y, from 2 October. It did not inform Mr Y at the time.
- Mrs Y’s care plan was not updated to reflect this change.
- Mr Y visited Mrs Y on 22 November. Mrs Y presented as unwell; there was vomit on her clothing and on the bedroom floor. When Mr Y spoke to staff, he says they did not know Mrs Y had vomited. Mr Y suspects that Mrs Y had been unwell for some hours.
- The GP saw Mrs Y later that day and amended Mrs Y’s medication as this was a possible cause of the vomiting. The GP decided not to undertake any further investigations.
- On the evening of 23 November, the home recorded that Mrs Y had slept all day. Staff tried to wake Mrs Y at mealtimes to eat and drink, but she refused. The records show Mrs Y ate two sandwiches at 11pm before having a “settled night”.
- Mr Y visited on 24 November. He said Mrs Y had a persistent cough and had not eaten all day.
- The following day, a member of nursing staff (Nurse 1) noticed Mrs Y’s excessive cough. They verbally shared their concerns when handing over to the night staff who agreed to monitor Mrs Y throughout the night and seek further advice in the morning if Mrs Y’s cough continued.
- The home says Mrs Y was settled during the night and not observed to be coughing.
- Another member of nursing staff (Nurse 2) relayed concerns about Mrs Y’s health and queried a possible chest infection on 26 November. The staff member said they would arrange for Mrs Y to receive antibiotics via the NHS 111 service.
- During the evening of 26 November, staff recorded that Mrs Y had a settled night with “no cough noted during the night”.
- On 27 November a note made at 15:37 shows the home told Mr Y that attempts made by Nurse 2 to contact 111 were unsuccessful and that they would contact the GP tomorrow morning.
- Mr Y spoke to a different member of nursing staff (Nurse 3) on 28 November who had no knowledge of Mrs Y’s illness. The staff member commented that Mrs Y’s observations were normal, and the home would place her on the GP list for tomorrow. Mr Y relayed his concerns about the delay in seeking medical intervention. Nurse 3 agreed to contact the NHS ‘Rapid Response’ (RR) team.
- Nurse 2 had not considered GP intervention or the use of the RR team, despite their concerns about Mrs Y and the failure of 111 to respond.
- The Rapid Response team visited later that afternoon. Mrs Y did not cooperate with a full assessment, but the team decided that Mrs Y needed antibiotics to be delivered by a local pharmacy the next day. The home noted Mrs Y had not vomited in 24 hours. Mrs Y also had a settled night.
- On 29 November Mr Y called the home and spoke with Nurse 1 who confirmed that Mrs Y was up and about but appeared very tired. Nurse 1 confirmed that Mrs Y’s medication had not yet arrived. Mr Y decided to travel to the pharmacy and collect the medication and deliver in person to the home.
- Mrs Y saw the GP later that day as part of the routine GP clinic. Mrs Y declined any physical observations. The GP however noted that Mrs Y was mobile and advised the home to continue administering antibiotics and to monitor her general wellbeing.
- Around this time, Mr Y learned that Mrs Y’s hourly nighttime checks had been withdrawn by the home in October. Mr Y queried this, and the home agreed to reinstate the sighting charts, “to support any additional lines of enquiry you may have”.
- Mr Y said the home should maintain the sighting charts on a permanent basis because of Mrs Y’s frailty and her high risk of falling.
- On 1 December Mr Y spoke with a staff member who confirmed that Mrs Y appeared well and taking her antibiotics with nurse supervision. Mrs Y was no longer coughing or vomiting.
- Four days later, Mr Y visited the home and found Mrs Y in bed with vomit on the bedroom floor. He noticed that Mrs Y’s food and fluid intake was lower than normal and raised his concerns with a staff member. The home also recorded that Mrs Y had not eaten during the day but would “push food and fluid”.
- The home set up a food and fluid chart to monitor Mrs Y’s intake from 6 December.
- Mr Y has raised his concerns in writing with the Care Provider. I will not revisit all the written exchanges here, but I will summarise the key findings made by the Care Provider following its own investigation:
- Concerns about documentation have been noted and acted upon in a range of ways, such as 1:1 meetings, additional support and monitoring and reviewing care notes.
- Acknowledged that Nurse 1 should have made a record in the written handover log on 24 November regarding Mrs Y’s persistent coughing and vomiting. Handover documents need more detail.
- Accepts the home should have contacted Mr Y when it changed Mrs Y’s care plan to remove the hourly night checks. The November 2022 care plan should also have been amended to remove the wording about sighting charts. The Care Provider apologised.
- Hourly night checks will not be reinstated because there is no clinical need. Mrs Y spends a lot of time during the day in communal spaces and is seen and monitored regularly.
- Dissatisfied with the response, Mr Y approached the LGSCO.
Was there fault in the Care Provider’s actions causing injustice?
Medical intervention for Mrs Y’s illness
- Mr Y considers the home failed to seek timely intervention when Mrs Y first became unwell on or around 22 November. Having considered the available information, it is my view that there was a short and likely avoidable period of delay between staff first noticing signs of illness and seeking medical assistance for Mrs Y. The records show Mr Y first raised concerns on 22 November. Mrs Y saw a doctor who changed her medication to try and overcome the vomiting. Mrs Y appeared well and settled the following day. She then developed a persistent cough on 24 November but did not receive antibiotics until 29 November.
- It is my view that there was a lack of documented handover between staff members in the four days between 24 and 28 November. There was further confusion amongst staff between 27 and 29 November about the correct process to follow, with one staff member (Nurse 2) having no knowledge of the Rapid Response team. This is a potential breach of regulation 12.
- In response to Mr Y’s complaint, the Care Provider acknowledged that its record keeping was below the expected standard and the handover notes were poor. This is not in accordance with provider’s escalation policy which says that staff will use the SABARD system to record and escalate concerns. It apologised to Mr Y and explained the measures taken to improve record keeping. This is a potential breach of regulation 17.
- The short delay likely caused Mrs Y some avoidable distress and discomfort. Mr Y also experienced time and trouble in pursuing the matter and repeating his concerns to staff members who should have already known that Mrs Y was unwell. I also consider Mr Y experienced some distress.
Care planning and adherence to plan
- The Care Provider explained the need for hourly night checks are based strictly on clinical need. When Mrs Y first moved into the home, the Care Provider decided she needed hourly checks. The home then reviewed its position in October 2022 and withdrew the hourly checks without first speaking with Mr Y. The Care Provider has acknowledged this was wrong because it should have first consulted with Mr Y. This is a potential breach of regulation 9.
- The decision whether to place a resident on hourly night checks is based on clinical need and professional judgement. The LGSCO has no remit to comment on matters of professional judgement, unless there is evidence of fault in the decision-making process which calls the outcome into question.
- In this case, I have seen no documented evidence of the home’s rationale or clinical assessment when it removed Mrs Y from the hourly checks. I consider the home should have recorded this key decision to ensure compliance with regulation 17. I cannot therefore say with any confidence that its decision was taken properly and without procedural fault. This fault creates injustice in the form of uncertainty. Furthermore, recent copies of Mrs Y’s care plan still refer to hourly checks despite these having been removed. The latest care plan is dated 4 August 2023.
Food and fluid intake
- The Care Provider said it started a food and fluid chart from 6 December following a decline in Mrs Y’s intake. We asked for a copy of the charts. The records provided show Mrs Y’s intake since February 2023 to the present day.
- I have also reviewed Mrs Y’s MUST (Malnutrition Universal Screening Tool) chart. This shows a monthly record of Mrs Y’s weight. It is evident that Mrs Y did experience some weight loss at the beginning of 2023. However, Mrs Y’s weight has since increased, and she now weighs more than she did in 2021.
- Although there is no evidence of the home completing food and fluid charts between December 2022 and February 2023, I am not persuaded this caused a significant injustice. Mrs Y’s weight has increased, and the home has continued to monitor her. This is in accordance with its policy.
- Within four weeks of my final decision, the Care Provider has agreed to:
- Pay £400 to Mrs Y in recognition of the avoidable distress and discomfort which she experienced following the home’s delay in seeking medical intervention and treatment for a chest infection in November 2022;
- Pay £300 to Mr Y in recognition of the avoidable time, trouble and distress he experienced when trying to obtain appropriate treatment for Mrs Y. This payment also recognises the uncertainty caused by the home’s failure to record its rationale for removing Mrs Y from hourly sighting checks;
- Review the wording in pages 36 and 37 of Mrs Y’s current care plan. This is to ensure any reference to hourly sightings is correct and in line with the Care Provider’s current position on the matter. If the Care Provider removes the wording in the above-mentioned pages, it should make a documented record of the rationale and any professional judgement explaining why Mrs Y’s clinical need has changed. It should also formally consult with Mr Y; and
- Provide evidence of the service improvements it has already implemented, including the additional support, monitoring and reviewing of care notes.
- Within eight weeks of my final decision, the Care Provider should also:
- Remind staff and provide training about completing and reviewing care plans so they are person centered, clearly show changes in need and involve appropriate family or representatives; and
- Remind staff and provide training about completing appropriate handover notes and escalating concerns when a resident presents as unwell.
- I have completed my investigation with a finding of fault causing injustice for the reasons explained in this statement. The agreed actions will provide an appropriate remedy for the injustice caused.
Investigator's decision on behalf of the Ombudsman