Summary: Mrs X complained about the standard of care she received while staying at a care home. Mrs X said this caused her health to worsen. We have found the actions of the care provider caused injustice to Mrs X. To remedy the injustice caused the care provider agreed to apologise to Mrs X, make a payment to her to recognise the distress caused and carry out a service improvement.

The complaint

1. Mrs X complains about the standard of care she received at a care home run by Care UK Community Partnerships Limited. Mrs X says her health deteriorated whilst she was staying at the 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 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))

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How I considered this complaint

4. As part of this investigation I considered the information provided by Ms X and the care provider. I discussed the complaint with Ms X over the telephone. I made enquiries with the care provider and considered the information received in response. I sent a draft of this decision to Mrs X and the care provider for comments.
5. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Law and guidance

6. 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.
7. Regulation 9 says care providers must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate, meets their needs and reflects their personal preferences, whatever they might be.
8. Regulation 10 says people using care services should be treated with dignity and respect.
9. Regulation 17 says care providers must “maintain securely an accurate, complete and contemporaneous records 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”.
10. In February 2023 we 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”. We also said, “Care providers compiling accurate records enable us to reach robust findings. However, if there are gaps in recording or a conflict of evidence, we can make findings based on the balance of probabilities”.

Background

11. Mrs X has care needs and lives at home with her husband. In April 2023, Mrs X arranged to go into a care home for a temporary stay whilst her family were on holiday.
12. In late March 2023, the care home carried out a pre-admission assessment for Mrs X and produced a care plan detailing Mrs X needs. The notes from this plan said:
• Mrs X needed a hoist for all transfers and needed a hoist for using the bath and being washed in bed. Mrs X needed two staff members along with the hoist to wash her.
• Mrs X was a vegetarian.
• Mrs X had exercise equipment she needed to use daily for one hour and needed assistance with this.
• Mrs X had a CPAP machine for her sleep apnoea and staff should regularly check to see if the CPAP machine had leaked at night and restart it if it had.
• Staff should constantly check in on her to see if there was a leak from her CPAP machine and clean the nasal cannula every four nights.
• Staff should reposition Mrs X every four hours.
13. Mrs X moved into the care home on 6 April 2023. On 8 April 2023, a manager met with Mrs X to discuss her routine and agreed staff would carry out her personal care and exercises after breakfast each day.
14. On 11 April 2023, a manager met with Mrs X and agreed to tell the chef to make her food separately and put a bowl of fruit in her room.
15. On 17 April 2023, Mrs X left the care home.

Mrs X’s complaint

16. Mrs X made a formal complaint to the care provider in early July 2023 about the standard of care she received while in the care home. Mrs X said:
• The temperature was very high in the communal areas so she could not use it as it caused her one of her health conditions to worsen. Mrs X said she had to stay in her room.
• The care provider knew Mrs X was vegetarian but no vegetarian food was available. Meals included things like one round of sandwiches for an evening meal. Mrs X said the only vegetarian options were things like bread or potatoes. Mrs X said the food options could not provide her with a balanced diet which she needed for her type II diabetes.
• She only had her teeth cleaned once during her stay and the bath was not suitable for her to use as she could not sit upright unsupported. Mrs X said the hoist for the bath had been removed so she could not use it. Mrs X said she did use the shower initially but staff could not find a shower commode chair and staff could not wash her properly in the shower.
• The staff could not reposition her CPAP mask and ended up breaking the mask. One night she was left without the mask so could not sleep. Mrs X said due to the care staff not being able to reposition her mask properly she was not able to sleep properly during her stay.
• She has very limited movement and it was agreed she would be moved every two hours. This did not happen and staff left her in chairs for hours at a time. At night Mrs X said she was supposed to be repositioned every four hours but this was not done unless she asked.
• Staff made her feel like she was a nuisance and carers were dismissive and unhelpful.
• Staff did not have time to help her use her exercise equipment.
• Staff took no action even though she told them her health was suffering as a result of the treatment she was receiving. Mrs X said by the end of her stay her temperature had dropped and blood pressure was very high.
• Her son arranged for one to one help from 8am to 8pm. However the care provider kept calling this carer away to do other jobs so Mrs X did not receive one to one help.
17. The care provider’s final position on Mrs X’s complaint was as follows:
• The temperature of the care home communal areas was never brought to the attention of staff.
• The care home had a three week rolling menu and there was always a vegetarian option. The care provider said it asked the chef to visit Mrs X to discuss meal choices and made a fruit basket available in her room.
• The care notes showed staff helped Mrs X with oral care every day apart from 7, 8 and 12 April 2023. However the care provider apologised for staff not taking initiative to help with oral care. The care provider said it was now checking on a daily basis whether residents had their teeth cleaned. The care provider said the preadmission assessment did not highlight Mrs X needed a ceiling hoist for bathing, nor did she ask for one. The care provider said it was a case of staff being unaware of Mrs X’s bathing needs rather than being unwilling to help.
• The care provider said it would provide staff with training around the use of CPAP machines, but it could not find any records of Mrs X not being able to wear her mask.
• There was no information given to the care provider which said Mrs X needed repositioning every two hours. The care provider said Mrs X was repositioned at least every four hours and provided details of the number of times per day she was repositioned during her stay.
• The care home was not run on skeleton staff and the staffs records were accurate. The care provider apologised if Mrs X felt she was a nuisance.
• The care provider said it offered Mrs X assistance with her exercises but there were a few gaps and some occasions where she declined. The care home apologised for the times where this was not offered.
• Care staff called the out of hours GP when they found Mrs X’s blood pressure was high. The GP told the care provider to monitor Mrs X’s blood pressure and call 999 if there was any deterioration. The care provider said it monitored Mrs X’s blood pressure and this had become lower by the next morning.
• The care provider said it arranged one to one care for Mrs X from 14 April 2023. The care provider said Mrs X received one to one care on 14 and 15 April 2023. On 16 April 2023, the agency sent a new member of staff. Rather than give Mrs X someone new the care provider assigned her a staff member from their team instead. The care provider also provided Mrs X with the number of times each day her call bell was pressed and answered.
18. Since the conclusion of the complaints procedure the care home has written off the charges for the one to one agency care provided to Mrs X at the end of her stay. This amounted to £864.
19. Mrs X remained dissatisfied and complained to the Ombudsman.

Findings

20. There are several concerns Mrs X raised about the standard of her care. I have separated my findings into each individual item.

The temperature of the communal areas

21. Mrs X said the temperature in the communal areas was too high and as a result she stayed in her room. There are no records about the temperature of the care home being raised in Mrs X’s care logs, or no records that Mrs X raised this with staff at the care home.
22. As there is no evidence to support Mrs X’s claims about the temperature of the care home, I have not found the care provider at fault.

Lack of vegetarian options

23. Mrs X said she did not get a proper choice of food and had to eat sandwiches for dinner or had to choose between potato and bread. Mrs X said there were times when she could not get to the dinner hall and did not eat. As a diabetic Mrs X said she needed a balanced diet. The care provider said it had a three week rolling menu with vegetarian options available.
24. Mrs X’s care plan says her food must be diabetic friendly and staff were to encourage her to have a well-balanced meals and offer vegetarian and diabetic friendly food to maintain her blood sugar levels.
25. The care notes showed the care provider asked its chef to serve her food separately and put a bowl of fruit in her room. While the care notes sometimes mentioned Mrs X had a meal there are no records available to show what Mrs X ate for meals or if she ate at all. As staff were supposed to ensure her dietary needs were met, it would have been useful to keep some sort of records of Mrs X’s food intake. Failure to do this amounts to fault.
26. As Mrs X and the care provider disagree about the food available, it is difficult to know what happened with out further evidence. The lack of records about what Mrs X ate will cause uncertainty about whether Mrs X received a balanced diet which was vegetarian and diabetic friendly.

Personal hygiene

27. Mrs X said she did not receive oral care and was unable to use the bath while at the care home.
28. The care records do not mention whether Mrs X had her teeth cleaned or had personal care on most of the days while she was at the care home. This is fault. As a result I cannot say whether Mrs X did in fact have her teeth cleaned as there are not adequate records of this.
29. In relation to washing Mrs X, her care plan said she needed a hoist for bathing. The care provider said it did not have a hoist for this, therefore I cannot see how Mrs X was able to use the bath. The care notes showed she only seemed to be washed in her bed by staff. This was fault. Mrs X said in her complaint that she wanted to use the bath so she could wash properly. By not having the correct equipment in place meant that Mrs X did not receive person centred care in relation to her bathing.

Machine for sleep apnoea

30. There are only two records about Mrs X’s CPAP machine in the care notes. One on 7 April 2023 when she first came to the care home and another record on 12 April 2023, where Mrs X asked staff to remove her mask so she could drink. Neither of these records mentions staff breaking the mask.
31. Mrs X’s care plan says staff should regularly check whether the CPAP machine has leaked at night. The care plan also says staff should clean out the nasal cannula every four days.
32. There are no entries in Mrs X’s welfare records which mention the CPAP machine. If Mrs X was reporting issues with this I would have expected this to have been mentioned somewhere. In addition, there is no mention in her welfare records or care notes about the CPAP machine working well or any records about staff cleaning the nasal cannula every four days.
33. The lack of records mean there is uncertainty about whether Mrs X’s CPAP machine was being operated properly. Given that the care provider decided to put staff on training around the use of CPAP machines suggests on balance there was uncertainty from staff about how to properly operate this.

Moving and repositioning of Mrs X

34. There is nothing in Mrs X’s care plan which says she should be moved every two hours. Therefore the care provider was not at fault for not repositioning her every two hours.
35. Mrs X’s care plan said she should be repositioned every four hours. While the care provider told Mrs X in its complaint response how many times it repositioned her each day, Mrs X’s repositioning charts show there were times when she was left for five or six hours without being moved. This was fault.

Attitude of staff

36. I have not seen any evidence to suggest staff were dismissive of Mrs X. Staff did agree with Mrs X to visit her after breakfast to offer personal care and exercises as they could not carry out these tasks anytime of the day. I do not consider this amounts to fault.

Mrs X exercises

37. The care notes showed staff helped Mrs X with her exercises during her stay. There were also times when Mrs X declined to do her exercises. However there were several times where there are no records of staff offering to help Mrs X with her exercises. This was fault. The care provider has acknowledged this and apologised to Mrs X.

Health deterioration

38. Near the end of Mrs X’s stay there are records of her blood pressure being high. However the care notes showed staff contacted the out of hours GP who told staff to monitor Mrs X’s blood pressure and call 999 if it got worse. Staff followed the advice of the GP therefore I do not consider there was fault here.

One to one care

39. Mrs X said she dd not receive one to one care as the carer kept being called away to carry out other duties at the care home. The records show Mrs X was assigned a one to one carer between 8am and 8pm for 14, 15, and 16 April 2024. I have not seen any evidence that Mrs X did not receive one to one care or that her carer was called away. I have not found fault here.
40. Even if we were to find the care provider at fault it has written off the cost of the one to one carers.

Overall conclusions

41. During Mrs X’s stay at the care home, she did not receive all of the care as set out in her plan. There are instances of Mrs X not being moved every four hours and not being offered oral care and assistance with her exercises. The care provider also did not have the correct equipment to allow Mrs X to use the bath.
42. This has caused injustice to Mrs X as she did not receive the care she should have.
43. In addition, some of the notes from the welfare checks and care records are not detailed enough to show whether Mrs X received suitable care. This has caused uncertainty about whether Mrs X received the correct care.

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Agreed action

44. Within one month of my final decision the care provider agreed to carry out the following:
• Apologise to Mrs X for the standard of care she received.
• Pay Mrs X £400 to recognise the distress and uncertainty caused to her as a result of the standard of care she received.
45. Within two months of my final decision the care provider agreed to:
• Consider how it monitors completion of tasks by its staff, including personal care and food intake, and how it ensures these are properly recorded in someone’s care records. The care provider should report back with any changes it makes to its monitoring and record keeping.
46. The care provider should provide us with evidence it has complied with the above actions.

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Final decision

47. I have completed my investigation and found that the actions of the care provider caused injustice to Mrs X. The care provider agreed to the above actions to remedy the injustice caused.

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Investigator's decision on behalf of the Ombudsman