Summary: There is evidence of fault by the care home, in that it failed to keep sufficiently detailed records which resulted in a lack of clarity and subsequent uncertainty for Mr Y’s relatives. The care home also delayed in responding to Mrs X’s complaint, for which it has already apologised.

The complaint

1. Mrs X complains about the quality of care provided to her late father, Mr Y, in a residential care home.

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The Ombudsman’s role and powers

2. 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. If they have caused a significant injustice or that could cause injustice to others in future we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
3. 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

4. I have:

• considered the complaint and the information Mrs X provided;
• considered correspondence between Mrs X and the care home, including the care home’s final response to the complaint;
• made enquiries of the care home and considered the responses;
• considered relevant legislation;
• offered Mrs X and the care home an opportunity to comment on a draft of this document, and considered the comments made.

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What I found

Relevant legislation

5. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 sets out the ‘fundamental standards’ which all care providers should meet in delivering care.
6. Regulation 9 Person Centred Care says the Care Provider must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate and meets their needs. Each person, and/or person lawfully acting on their behalf, must have all the necessary information about their care and treatment.
7. Regulation 17 of the 2014 Regulations requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.
8. An inspection by the Care Quality Commission in November 2022 concluded the service to ‘require improvement, in the areas:

• Is the services safe;
• Is the services well led

9. The inspection report noted concerns about using medicines safely, and inconsistencies in the amount of stock in place and the amount recorded.

Background

10. Mr Y was in late eighties and had Alzheimer’s disease. He moved into the care home in November 2022.
11. Mrs X says Mr Y did not receive satisfactory support with personal care, that he experienced a delay receiving prescribed medication, was isolated in his bedroom, and not taking part in social activities. She also says communication from care staff, was at times unsatisfactory.
12. Mrs X says, both she and sister were discouraged from visiting Mr Y when he had flu in late 2022. They both telephoned the care home every day and were advised not to visit but eventually decided to visit anyway. Mrs X cannot understand why they were advised not to visit.
13. Mrs X says one occasion her sister expressed concerns about Mr Y’s health to the owner of care home and was told to “back off” because Mr Y was now under ‘their’ care.
14. Mrs X’s sister visited Mr Y on 15 March 2023, during which she became concerned about his wellbeing. He looked yellow, his speech was slurred, and he appeared disorientated. Mrs X’s sister spoke to a member of staff, who said she would go and find a senior carer. Mrs X says her sister waited 30-minutes, but no one came to speak to her, she then had to leave. Once home, Mrs X’s sister telephoned the care home, she says a carer told her Mr Y’s presentation was probably medication related.
15. Mrs X says that prior to Mr Y’s admission to hospital he had appeared unwell for some weeks. She says care staff did not respond to concerns expressed by both her and her sister. She says this resulted in a deterioration in Mr Y’s health and subsequently his admission to hospital. On admission to hospital Mr Y was found to have a broken hip, pneumonia, a urinary tract infection, anaemia, and low oxygen levels. Mrs X believes the care home should have sought medical help for Mr Y sooner, and had they done so he may not have fallen and endured unnecessary suffering.

Information from the care home

16. The care provided a copy of Mr Y’s care plan. The document is detailed and comprehensive and sets out the support Mr Y required. It records Mr Y walked independently with a stick, that he could be unsteady, and he did at times, refuse medication.
17. Mr Y sometimes refused support with personal care and was reluctant to change his clothing. Care staff could find him challenging, and on such occasions, he needed the support of two carers. In the event of Mr Y’s continued refusal of support with personal care, care staff were to contact his family and ask that they visit and try to encourage him to wash. Mrs X says her sister was asked to visit Mr Y once to encourage him to have a bath, and she was never asked to visit to encourage Mr Y to wash.
18. A risk assessment was completed in respect of Mr Y’s mobility, his refusal of personal hygiene, behaviour which challenged carers, and any refusal to take medication. The document set out the action needed to address this.
19. A falls risk assessment was also completed, and Mr Y was considered at high risk of falls. To mitigate this, care staff were instructed to ensure he used his walking stick whilst mobilising and ensure, where possible, his environment was free of obstacles.
20. The care home says staff encouraged Mr Y to leave his room and partake in activities. There were occasions when he refused and wanted to remain in his room. This became more frequent as his disorientation to night and day increased as he would sleep more during the day.
21. The care home confirmed Mr Y had been ill in late 2022. It says it has no records to show Mr X and her sister were discouraged from visiting. The care home has provided no records of telephone contact with Mrs X and her sister.
22. The care home provided a copy of Mr Y’s medication administration record (MAR). This records the date and time medication was given and the total amount of each medication available.
23. The records show the care home was running low of one of Mr Y’s medication and that it requested more of the medication from his GP surgery on 8 February 2023. The care home says the medication was not a routine medication and was ‘out of sync’ with his regular medication cycle. An interim prescription was requested eight days prior to his medication running out.
24. When it was not supplied, the care home contacted the surgery on 12 February 2023, to chase the medication, and was informed of manufacturing problem. The care home says it contacted all the local pharmacies to discover there was none in stock. The pharmacy informed the care home the request would have to be referred to the GP for review.
25. The care home requested a medication review from the GP. The GP informed the care home, the medication would need to be reviewed the NHS mental health team.
26. The GP requested a Community Psychiatric Nurse (CPN) review Mr Y’s medication. The CPN contacted the care home on 6 March 2023 and recommended a medication at an increased dose.
27. The care home contacted the GP surgery the following day to request a prescription for the medication. When it was not received, the care home contacted the GP surgery daily to chase the prescription. The care home received the medication on 14 March 2023, when Mr Y received his first dose.
28. The care home says the CPN warned care staff the medication may make Mr Y drowsy. Because of this staff encouraged Mr Y to sit where staff could monitor him, but he was independently mobile and would move around as he pleased.
29. The care home says it has no record of Mrs X and/or her sister raising concerns about the attitude of care staff. It says, concerns raised by relatives are channelled through senior carers who will then speak to the relatives and where necessary, contact relevant professional bodies.
30. The care home’s records confirm care staff completed an e-consult referral to Mr Y’s GP on 15 March 2023. As the referral was not mentioned to Mrs X’s sister it can be assumed it was made after she spoke to the care home about her concerns.
31. On the morning of 16 March 2023, Mr Y’s confusion appeared worse. The records show care staff contacted the GP surgery to chase the referral made the previous day. Later that morning Mr Y had a fall at the care home and was admitted to hospital.
32. The care home provided a copy of the incident report detailing the events and the care staff’s response. The report confirms Mr Y had been acting out of character prior to the fall, and care staff suspected he may have a urinary tract infection and that the GP had been informed.
33. On admission to hospital, it was confirmed Mr Y did have a UTI infection, along with other serious health issues as set out in paragraph 15 above.
34. During Mr Y’s hospital stay, the records show his family contacted the care home to request it re‑assess him for return to the home, as it was their preference he return there. Mrs X refutes this, saying it was the hospital that contacted the care home.
35. Both the manager and deputy manager of the care home visited Mr Y in hospital to reassess his needs. Following discussion with the nursing staff it was concluded that Mr Y needed nursing care and would therefore not be able to return to the care home.
36. Mr Y passed away in April 2023 in a different care setting.
37. The owner of the care home says the family invited her to the funeral, which she attended and was welcomed by the family. She says no complaints were made during the time Mr Y was resident at the care home, and she always believed she had a good rapport with his family. The family dispute the invitation to Mr Y’s funeral They say after informing the owner of the care home about the funeral details, the owner said she attends all residents’ funerals, and they did not wish to say otherwise or appear rude.
38. Mrs X submitted a formal complaint to the care home in October 2023. She received no response, so she sent a copy of the complaint via email on 13 December 2023. She received no response, so she contacted the Care Quality Commission, who advised her to make a complaint to this office.
39. Following involvement from this office, the owner of the care home acknowledged she had failed to deal with the complaint properly, which she now regrets and for which she offers her sincere apologies.

Analysis

40. It has not been possible to come to a finding on many of the issues raised in this complaint because the Care Provider failed to keep records of discussions with Mrs X and her sister. This is not only poor practice, but a potential breach of the regulations. The Care Provider should have kept accurate records on all occasions Mrs X and her sister expressed concerns, and how these concerns were acted on/monitored. It should also have kept records of telephone conversations and any advice/information given. Doing so, would have provided clarity and enabled the Care Provider to evidence its claims/actions.
41. On the matter of Mrs X’s allegation that care staff advised her and her sister not to visit Mr Y whilst he was ill in late 2022. I find it improbable that they would refrain from visiting unless they had been advised to do so.
42. If a family member raises concerns about a residents’ health, then it would be appropriate to request a GP visit as soon as possible. Assumptions about the cause of a change in a resident’s behaviour/presentation should not be made. Whilst the care home did contact the GP the day before Mr Y fell, there is a clear indication from the diagnosis on admission to hospital that Mr Y needed urgent medical attention and his condition was not just because of the fall. This would support Mrs X’s account that she and her sister had raised concerns earlier than is recorded on the care home’s records. Whilst it is understandable that Mrs X and her sister have been left with a degree of uncertainty about what happened, and the impact on Mr Y. I cannot say this contributed to Mr Y’s demise. Mr Y died some months later in a different care home.
43. Whilst the records show the care home requested a repeat prescription of Mr Y’s medication when it was running low, it is not clear if, and for how long, Mr Y was without medication, and if care staff alerted the GP to this. There was a delay in the care home receiving the increased medication, which was beyond its control.
44. The owner of the care home acknowledges she failed to deal with Mrs X’s complaint properly. She has apologised to Mrs X for this in her complaint response of 19 February 2024.

The care home’s response to the draft decision statement

45. Since this complaint, the care home says additional members of care staff have been assigned “…to complete a Record- Keeping training programme in order to improve the quality and accuracy of future records”.
46. The Ombudsman’s office will require evidence of this.
47. The care home says medication is audited weekly by the senior care staff which identifies any medication which is running low. The deputy manager audits medication on a fortnightly basis and the registered manager carries out a monthly audit to oversee and check all procedures. Medication which is running low will be requested from a GP and recorded. Senior staff will also document any follow-up chasing requests. We will require evidence of this, within three months of the date of the final decision.
48. Management at the care home will ensure that any future complaints are dealt with in a timely manner and according to the complaints policy.
49. Subject to receiving the required evidence, I consider the above action adequality addresses the failings highlighted in this complaint.

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Agreed action

50. The care provider should, within four weeks of the final decision:

• apologise for the failure to record of contact/discussions/expressions of concern with Mrs X and her sister, and the uncertainty caused as a result. And provide a copy to this office.

51. Within three months of the final decision:

• provide evidence of completion of the action set out in paragraph 45.

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Final decision

52. There is evidence of fault by the care home, in that it failed to keep sufficiently detailed records resulting in a lack of clarity and subsequent uncertainty for Mr Y’s relatives. The care home also delayed in responding to Mrs X’s complaint.
53. The action set out in paragraphs 44, 45, 47 & 48 represents a suitable way to settle complaint.
54. It is on this basis; the complaint will be closed.
55. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share a copy of the final decision with CQC.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman