Summary: Ms C says the care provider commissioned by the Council failed to provide adequate care to her father. There is evidence of the care provider, acting on behalf of the Council, failing to address issues relating to Ms C’s father’s presentation and health and failing to keep proper records. An apology and payment to Ms C is satisfactory remedy as another council is responsible for addressing the outstanding issues with the care provider.

The complaint

1. The complainant, whom I shall refer to as Ms C, complained the care provider commissioned by the Council failed to provide adequate care to her father. Ms C says failures by the care provider resulted in her father’s health deteriorating and the care provider failed to act when she raised concerns.
2. Ms C says failures by the care provider acting on behalf of the Council has caused her significant distress as she feels her father’s death was unjust.

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The Ombudsman’s role and powers

3. 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)
4. 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 actions of the care provider, I have made recommendations to the Council.
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)

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How I considered this complaint

6. As part of the investigation, I have:
• considered the complaint and Ms C's comments;
• made enquiries of the Council and considered the comments and documents the Council provided;
• considered the records the care provider submitted.
7. Ms C and the organisation had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.
8. 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.

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What I found

The fundamental standards

9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve.
10. Regulation 12 says care providers must assess risks to people's health and safety during any care and make sure staff have the qualifications, competence, skills, and experience to keep people safe.
11. Regulation 13 covers safeguarding service users from abuse and improper treatment. The intention of this regulation is to safeguard people who use services from suffering any form of abuse or improper treatment while receiving care and treatment. CQC say providers must have a 'zero tolerance' approach to all kinds of abuse including neglect. Providers must take appropriate action without delay through having 'robust procedures' in place to investigate incidents.
12. Regulation 14 says care providers must meet service user's nutritional and hydration needs. The associated guidance says care providers:
• "must include people's nutrition and hydration needs when they make an initial assessment of their care, treatment and support needs and in the ongoing review of these. The assessment and review should include risks related to people's nutritional and hydration needs.
• providers should have a food and drink strategy that addresses the nutritional needs of people using the service."
13. 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."

What happened

14. Ms C’s father entered a nursing home as a temporary placement in August 2022. The Council arranged that placement. The placement is in another council’s area.
15. On 3 September Ms C’s father was found on the crash mat next to his bed. The registered nurse on duty checked him and identified no injuries. Ms C’s father’s vital signs were checked and were within the normal range. The care provider continued to monitor Ms C’s father over the next 72 hours.
16. Later in September when visiting her father Ms C found him slumped in a chair, unresponsive and unable to lift his arm. Ms C raised concerns with care staff as she was concerned her father was having a stroke. The care staff Ms C spoke to told her he had improved from the previous day. Later that week Ms C’s father was taken into hospital. He had experienced a mini stroke. Ms C’s father was discharged back to the nursing home on 4 October. By that point Ms C’s father’s weight had gone down significantly.
17. At a meeting with the Council’s social worker and the care provider on 7 October Ms C asked for her father to be considered for a long-term placement as his needs had increased. The Council agreed that.
18. On 9 November Ms C’s father was found on the crash mat next to his bed. The registered nurse on duty checked Ms C’s father and identified no injuries. His vital signs were within the normal range. Ms C asked the Council to consider installation of bed rails, as she had requested when her father first went into the nursing home. The care provider decided bed rails were not necessary as the bed was on the lowest setting and a crash mat was in place.
19. On 22 November Ms C’s father was found on the crash mat next to his bed. The registered nurse on duty checked him and identified no injuries. His vital signs were within normal range.
20. Ms C’s father was seen by the GP on 23 November due to concerns about him not sitting upright. The GP recommended the care provider monitor fluid intake.
21. Ms C’s father was admitted to hospital on 28 November where it was identified he had 0% kidney function, was dehydrated and had sepsis.
22. Ms C’s father sadly passed away on 4 December.
23. Since then the care provider has considered Ms C’s father’s case and has identified some failings in its provision of care. The council in which the nursing home is situated has carried out a safeguarding enquiry. As part of that it has required the care provider to complete an action plan and will be arranging monitoring to ensure actions identified are followed up on.

Analysis

24. Ms C says the care provider commissioned by the Council failed to provide adequate care to her father. Ms C says her father deteriorated rapidly in the nursing home, lost a lot of weight and was admitted to hospital where it was found he had experienced a mini stroke despite the fact she had raised concerns he was experiencing a stroke earlier that week. Ms C also says when her father was admitted to hospital on the second occasion, shortly before his death, he was dehydrated, had 0% kidney function and had sepsis.
25. As I said in paragraph 4, as the Council commissioned the care it remains responsible for the care provider's actions. I note though the care provider has completed its own investigation and upheld many areas of the complaint. The care provider reached the following findings:
• Ms C's father received a level of care that was far below the standards to be expected;
• there were failings of communication, including failure to communicate when concerns were raised;
• there was a lack of effective oversight by management;
• a lack of care, respect and dignity was shown to both her father and her family;
• the attitude of staff was, on occasion, disrespectful and demonstrated a task orientated approach rather than a person centred, empathetic one (noting staff were not reactive enough in recognising when Ms C's father required additional care and attention, there was a reliance on external professionals to guide care rather than a culture of critical thinking and the care team too readily accepted his deteriorating condition rather than asking why it was taking place and questioning what the care provider could do better to support him);
• there were repeated failures to document care actions;
• the concerns Ms C raised in September and October 2022 should have been dealt with more effectively before the complaint in December 2022;
• the falls risk assessments were not completed accurately as they overlooked the antihypertensive medication Ms C’s father was taking and recorded her father took adequate hydration which was unlikely to be true;
• a formal falls risk assessment in relation to providing bed rails, which Ms C had asked for, was not completed and communication about why the home did not consider that appropriate did not take place. It also did not explain it had carried out 72 hour monitoring following her father's falls;
• on one occasion Ms C's father was dressed incorrectly as his shirt was worn back to front which suggested concerns about the level of support and supervision he received in getting dressed;
• it is not recommended for blisters to be deliberately burst and this would normally only be done in a care setting under the guidance of the tissue viability nurse and therefore the carer who deliberately burst Ms C's father's blister should not have done so;
• care records show consistent concerns regarding the deterioration in Ms C's father's health and mobility but there were no documented actions taken or communications with Ms C to explore the reasons for his decline or offer an appropriate caring response;
• the dramatic weight loss did not trigger wider communication between the home, the multi-disciplinary team and the family on the underlying causes and an agreement for the appropriate care required from that point;
• there was poor practice in the home around documenting fluid intake as carers documented fluids offered rather than confirming the quantity drunk. As a result the information on fluid intake is woefully inaccurate and contributed to the lack of care; and
• although the requirement for support with eating and drinking was recorded in the care plan it was not robust or specific enough which led staff to be unclear as to the level or intensity of supervision required.
26. The care provider confirmed it had put in place training and reminders to staff.
27. In light of those findings I am satisfied Ms C's father received inadequate care during his period in the nursing home. The nursing home failed to address a deterioration in Ms C's father's health and weight despite Ms C raising concerns with it. I am concerned about that given the weight loss was significant and yet the food charts kept by the care provider suggested Ms C's father was eating a full portion on most occasions. I would have expected that to prompt the care provider to investigate the weight loss further. Had it done so it might have identified issues with care staff failing to properly supervise Ms C's father after his abilities deteriorated to ensure he ate the food put in front of him. That is fault.
28. I am also concerned about the care provider's failure to identify issues with the recording on its fluid charts. It is now clear care staff were recording the amount of fluids offered rather than consumed. That, in itself, is fault. Given those fluid charts suggested, wrongly, Ms C's father was drinking all the fluids offered to him I would have expected the care staff to have identified an issue with his urine output and there is no evidence they did so. That again is fault. Had that issue been identified it is likely, on the balance of probability, the issue with how the fluid charts were being completed could have been identified at an earlier stage. That has left Ms C with some uncertainty about whether some of the issues her father experienced could have been avoided.
29. The care provider has also accepted its risk assessments were not properly completed following Ms C's father's falls. That, again, is fault. I am satisfied though the care provider did carry out further checks on Ms C's father following his falls. I would not expect the care provider to send a resident to hospital every time a fall occurred though. That would not be normal practice where a resident has been assessed as not having sustained any injuries. The documentary evidence I have seen satisfies me no injuries were identified following the three falls. Nevertheless, failure to keep proper records, as identified by the care provider, is fault.
30. I understand Ms C's concern about the failures the care provider has identified, especially as she had raised her own concerns about her father's deterioration with the care provider and there is no evidence the care provider acted on those concerns. Nor is there any evidence the care provider acted on the concerns after Ms C met with the home manager. I understand why, in those circumstances, Ms C would believe inadequate care by the care provider caused or contributed to her father's deterioration and subsequent death. However, only a coroner can comment on the cause of death or contributory factors in a death. That is not something the Ombudsman can determine. I am satisfied though failures by the care provider, for which the Council is responsible, likely caused Ms C significant distress and has left her with some uncertainty about whether the situation would have been different had the care provider acted as it should have done. That is a serious injustice. To remedy that I recommended the Council apologise to Ms C and pay her £500. It is not now possible to remedy the injustice to Ms C's father as he has sadly passed away. The Council has agreed to my recommendation.
31. In normal circumstances I would make some procedural recommendations around changes to the care provider's practice for the Council to monitor. However, in this case the care provider is in another council's area and therefore the Council is not responsible for any oversight or monitoring of the care provider. I am satisfied though the council in whose area the nursing home is situated is involved in assessing safeguarding issues at the home because of Ms C's father's case. I am satisfied it is taking action to address those concerns.

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Agreed action

32. Within one month of my decision the Council should apologise to Ms C and pay her £500.

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Final decision

33. I have completed my investigation and uphold the complaint.

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Investigator's decision on behalf of the Ombudsman