Summary: The Care Provider failed to deliver aspects of Mr X’s care plan. It also failed to follow its complaint process when responding to Mrs X’s complaint. This caused Mrs X distress and uncertainty. The Care Provider has agreed to apologise, make a payment to Mrs X and review its record keeping.

The complaint

1. Mrs X complained about the standard of respite care her late husband, Mr X, received from Castle Mead Court care centre (the Care Provider). She says Mr X’s mobility declined and he returned home with an open pressure sore, causing Mrs X distress. She wants the Care Provider to accept its failings and apologise.

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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. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
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)
5. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

6. I considered evidence provided by Mrs X and the Care Provider as well as relevant law, policy and guidance.
7. Mrs X and the Care Provider had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Standards of Care, Policies and Procedures

Fundamental Standards of Care

8. 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. The standards include:
• providers must make sure each person receives appropriate person-centred care and treatment based on an assessment of their needs and preferences (regulation 9).
• providers must make sure that people who use their services have adequate nutrition and hydration to aid good health. People must be provided with appropriate food and drink and any support they may need to achieve adequate nutrition (regulation 14);
• providers must have an effective and accessible system for identifying, receiving, handling and responding to complaints (regulation 16).
• providers must securely maintain accurate, complete and detailed records about each person using their service (regulation 17).

The Ombudsman’s guidance on good record keeping

9. We published guidance on good record keeping for care providers in February 2023. The guidance says care providers should ensure all records are accurate, comprehensive and updated with new information.
10. If there are gaps in recording, or a conflict of evidence, we can make findings based on the balance of probabilities. This means we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.

The Care Provider’s complaint policy

11. The Care Provider’s complaint policy says it will respond to complaints within 28 working days. If it needs more time to investigate it will write to complainants with an updated timescale.
12. If a complainant is unhappy with the Care Provider’s response they can request a full review by a member of the senior leadership team.

What happened

13. In the summer of 2024 Mrs X placed Mr X in respite care at the Care Provider for two weeks. The Care Provider’s risk assessments and care plan showed:
• Mr X was at high risk of falls. Two staff should accompany Mr X on short walks, and he should use his wheelchair on longer journeys.
• Staff should supervise Mr X’s eating and drinking and ensure he drank enough fluids through the day.
• Mr X had poor skin integrity and staff needed to reposition him every four hours. Staff also needed to check Mr X’s skin when delivering personal care and support him to stand to relieve pressure.
• Staff should support Mr X to use the toilet to promote his independence.
• Staff should ensure Mr X’s hearing aids were working correctly.
14. The Care Provider carried out several assessments of Mr X within 24 hours of his admission. This included skin care, movement and falls assessments.
15. Mr X’s daily care records show staff carried out his personal care in line with his care plan, with monitoring of his eating and drinking and support using the toilet. On day one of his care, Mr X suffered a fall but sustained no injuries. The Care Provider carried out checks on Mr X for the next 72 hours. It was satisfied Mr X had not suffered any further injuries because of the fall. Mr X suffered two more falls on day four and five of his care. The records again showed no injuries. The Care Provider reviewed Mr X’s falls assessment following the new falls.
16. A few days later, Mr X suffered a skin tear to his hand after catching it on a chair. The Care Provider’s records show the tear was healing well over the following days. Mr X suffered another fall shortly before the end of his stay, with staff discovering him on the floor. The Care Provider again reviewed Mr X’s falls assessment.
17. A few days after Mr X returned home, Mrs X complained to the Care Provider about his condition. She said his mobility had worsened and he could not even stand. She said Mr X’s home carers had discovered a pressure sore and asked if the Care Provider had used Mr X’s cushion when he used his wheelchair, as it had not been returned. She also said the Care Provider had lost Mr X’s hearing aid for several days when he was at the Care Provider, and her son had discovered Mr X sat in the dark on one occasion.
18. Mr X died later that month.
19. The Care Provider responded to Mrs X’s complaint in October 2024. It said its records showed Mr X had variable mobility. It said it had used the cushion, and it had been in the laundry drying when lost. It accepted it had failed to carry out a body map of Mr X and apologised for poor communication about the pressure sore. It also apologised for losing Mr X’s hearing aids for several days. It said its team needed more training on working with deaf residents. The Care Provider said following Mrs X’s complaint it would improve its communication, carry out training on skin changes and caring for residents with hearing and sight loss. It said if Mrs X remained unhappy, she could ask for a stage two review within 28 days.
20. Mrs X responded to the Care Provider within 28 days. She said it had not responded to Mr X being left in the dark and she did not feel it had analysed why the issues with Mr X’s care had happened. She said the pressure sore was evidence of poor care, while the wet cushion showed Mr X was not being changed enough or supported to go to the toilet. She said Mr X had needed one carer once a day before his stay and needed two carers four times a day after.
21. A member of the senior leadership team responded giving more details of Mr X’s care and his refusal to cooperate at times. It said it had carried out assessments of Mr X and there was no evidence of neglect. It again offered Mrs X the right to a review of her complaint if she remained unhappy. Mrs X complained to the Ombudsman.

My findings

22. The Care Provider assessed Mr X’s care needs within 24 hours of his admission for respite care and reviewed the assessments following Mr X’s falls. The daily care records show the actions the Care Provider took to deliver Mr X’s personal care, nutrition and fluid intake. However, there is less detail of when the Care Provider repositioned Mr X. Mr X’s daily care records contain only a few entries giving details of when this happened. The failure to keep accurate records is fault and is not in line with the CQC fundamental standards. The Care Provider has also accepted it failed to properly check Mr X’s skin integrity before he returned home with a pressure sore. Given the lack of records and Mr X’s pressure sore, on balance, I find the Care Provider failed to follow Mr X’s care plan regarding repositioning and support to stand. This was fault.
23. Mr X has since died and we are unable to remedy any injustice caused to him by the care home's actions. However, the faults by the care home caused Mrs X distress and uncertainty over whether there could have been a better outcome for Mr X.
24. When Mrs X complained about Mr X’s care, the Care Provider failed to respond within 28 days and offered Mrs X a further review following its stage two response. The Care Provider failed to follow its complaint process, causing Mrs X further uncertainty.
25. In response to our enquiries the Care Provider said it had implemented a new electronic care plan system to ensure it monitored care interventions and escalated where necessary.

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Action

26. Within one month of the final decision, the Care Provider has agreed to:
1. Apologise to Mrs X for the distress and uncertainty caused by the failings identified in this decision. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Care Provider should consider this guidance in making the apology.
2. Pay Mrs X £500 to recognise the distress and uncertainty caused by the failings identified in this report.
27. Within three months of the final decision, the Care Provider has agreed to review the changes it has made to its record keeping against the Ombudsman’s guidance on good record keeping. This is to ensure its care records accurately reflect how it delivers the care set out in a resident’s care plan.
28. The Care Provider should provide us with evidence it has complied with the above actions.

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Decision

29. I find fault causing injustice which the Care Provider has agreed to remedy.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman