Summary: There was fault on the part of the care provider which led to actual suffering and distress for Mr X and distress for Mrs X. The care provider acknowledges fault in its record keeping and offers a goodwill payment. It should make a more significant payment to reflect the injustice caused by its actions.

The complaint

1. Mrs X (the complainant) says the care provider failed to provide an adequate standard of care for her disabled husband while he was in respite care. As a result he needed medication and urgent treatment for an infection when he came home and took some months to recover his health.

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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))
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(1), 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. I spoke to the care provider.
7. Mrs X and the care provider had an opportunity to comment on earlier draft decisions and I consider their comments before making a final decision.

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What I found

Relevant law and guidance

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.
9. Regulation 10 says service users must be treated with dignity and respect.
10. Regulation 14 says the nutritional and hydration needs of service users must be met. The guidance says 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.
11. Regulation 17 says care providers must 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.
12. In 2023 we issued guidance to care providers on good record keeping. We said “Care providers compiling accurate records enables 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.” We added, “We are likely to find a care provider at fault where records … are inadequate for their purpose, or where they omit essential information”.

What happened

13. Mr X, who is disabled and uses a wheelchair, went into Rose Lodge for a period of two weeks respite care. He normally had domiciliary carers to manage his personal care. The pre-admission assessment from the home noted “(Mr X) likes to be hoisted to a commode on a morning and then showered”. It noted he had a catheter in situ and had had many infections previously. It went on “(he) needs to drink 4 litres per day”. This was repeated as part of his daily dietary needs. Mrs X said her husband was looking forward to the respite care as a ‘holiday’. She said there were a few problems at the pre-admission visit – there was no bedroom available for him to see, for example - but the planned admission went ahead on 18 May 2024.
14. The care provider says the stipulation about the amount of fluid was not a clinical need. Mrs X says that in this case it is an “established and necessary component of his individual care regime, required to manage his catheter and prevent infection”. She points out that care plans are supposed to be personalised and not conform automatically with the average,
15. A note for 24 May, written by a member of the nursing staff, stated that Mr X had developed a ‘burst blood blister’ between 4 and 5 cm across on his buttock. The writer noted they had applied a dressing and completed a body map.
16. A ‘blister’ on Mr X’s right heel was noted on 27 May and he was given repose boots to wear to protect it. The care notes show that Mrs X was informed and that staff assessed and monitored the blister.
17. The care records for 01 June, the final day of Mr X’s stay, stated there were “no issues or concerns”.
18. Mrs X says during her husband’s stay in the home it was frequently difficult to speak to him by telephone, with staff often saying they were too busy, or there wasn’t a spare phone available for him to use. She says their daughter who went to collect him at the end of his placement was horrified at his condition. She says he was very unwell, the urine in his catheter bag was brown in colour, his feet were very swollen and the blister on his heel was deep and filled with fluid. She said his water bottle was empty, none of his possessions had been made ready for his return home and he was not properly dressed, with his trousers not pulled up and his incontinence pad out of place and showing past his waistline. In addition, she says he was “exceptionally quiet” and not like his normal self.
19. The care provider says Mr X’s daughter did not raise these concerns at the time. In contrast Mr X’s daughter has supplied an account of her collection of her father where she says she went to the office after she saw her father’s poor condition, and raised her concerns but staff there said they had no concerns. She says, “When I queried the use of Repose boots and blister, they stated the boots were due to swelling but did not demonstrate awareness of the underlying cause or urgency and knew he had a blister but were not concerned. I requested assistance to adjust his clothing, which staff provided without displaying any concern for his wellbeing. I then asked to speak with the nurse on duty. The nurse assured me that my father was “fine” and expressed no concerns, despite me highlighting his current state. She handed me his medication”.
20. Mrs X has provided evidence that the carer who came to provide his care at home that day called the out of hours nurse to attend because of their concerns about Mr X’s condition – “both swollen legs from calves to toes”, “left upper leg tender… and painful”.
21. The nursing records show “bilateral leg oedema” and that Mr X had started taking antibiotics for a suspected UTI. Mr X had a large blister on his heel which Mrs X understood from the nurse was probably caused by being left in bed too long with his legs in a “frog-leg” position. He had a reddened area on his buttocks which was wet and apparently not attended to. His ankles and feet were very swollen. The nurse took photographs for her files. Mrs X has provided us with copies of the photographs.
22. One of the nursing staff who visited Mr X during this time raised a safeguarding alert because of her concerns of neglect or acts of omission. She noted that Mr X had returned from the care home “dehydrated and with a UTI”.
23. Mr X required district nursing care on a daily basis for a week after his return from respite care.
24. Mr X told Mrs X he had not been hoisted and dressed first thing every day as usual: it was often mid or late morning by the time he was out of bed. He said he was not hoisted on to the commode at any point during his stay but given pads to use instead. He said he was not showered at any point during his stay. He said he was not given water regularly despite this being specified on the pre-admission assessment and care plans.
25. Mrs X complained formally to the care provider on 12 June.
26. The care provider responded on 23 July. The customer care manager apologised the Mrs X had had difficulty speaking to Mr X by phone while he was resident. She said although the care notes showed Mr X had a full body wash every day, she acknowledged this was not as specified in his care routine. She said the care notes gave a general picture on daily interactions and did not say whether Mr X had been offered or received a shower, or declined it. She accepted there was no documentary evidence that he had been supported to use the commode, although she said this did not mean it had not happened.
27. The customer care manager apologised that the sore on Mr X’s heel had not been observed sooner. She said all staff would receive more training in tissue viability. She said she accepted that Mr X had spent most mornings in bed. She said although this did not reflect the preference Mr X had shown in his care plan, Mr X had capacity to make his own decisions and was able to request support sooner if he wished.
28. In respect of Mr X’s fluid intake, the customer care manager said although staff were “confident” his fluid intake was good for the first three days of his stay, there was no documentary evidence. She said as his fluid levels appeared to be good and he was not at risk of dehydration, there was no reason to chart his fluid intake. She points out that staff observed Mr X drinking and recorded in his notes that his food and fluid intake was good, which led to their statement of confidence. She said he asked for his water bottle to be refilled when he wished and explains that he had no hesitation in seeking support when he required it. Mrs X says it is unfair to have expected Mr X to have constantly reminded staff of the need to adhere to his care plan.
29. The customer care manager said staff at the home acknowledged and apologised that personal care was not always provided at the level it should have been. She said there were “lessons to be learned” about the standard and detail of the care records. She offered £500 as a gesture of goodwill.
30. The local council’s safeguarding team indicated to Mrs X that its contracts monitoring team would check complaints about the home in case improvements were required. The care provider says this is usual practice and the safeguarding team took no further action.
31. Mrs X complained to us. She said eight months after the respite care Mr X was still not back to the state of health he had enjoyed when he went into the home.
32. The care provider acknowledges that while staff were confident Mr X was taking enough fluids, there is no evidence in form of fluid intake charts to prove that. She says there were no concerns about dehydration or infection, and says that he had a good urine output which was not dark in colour. In addition she points out that there would have been no requirement to complete fluid charts after the first three days in any event given that Mr X’s intake was deemed by staff to be more than adequate.
33. The care provider acknowledges that there are no records to say whether Mr X had been offered showers or not She says he received a full bodywash every day. She accepts the need for better documentation and record keeping.
34. Daily care notes from the care provider for the period of respite care evidence that care staff believed Mr X was “settled”. The notes describe the continence care and personal hygiene given and noted that he would sometimes decline the offer of a shave. Many notes reference the emptying of his catheter bag and that it was draining well: no concerns were noted about small quantities or dark colour of urine.
35. The care provider has given me details of a new recording system it now has in place which enable staff to record interactions with residents in more detail. Staff members carry a handset which alerts them to required tasks. The care provider says, “Every interaction has the opportunity for a daily note to be recorded. The expectation is that wellbeing and personal care interactions should contain a daily note that is person-centred and captures social/relationship building i.e. the topic of conversation, how that person is feeling. It should also capture what that individual has been able to do for themselves, and what support they asked the staff for.
36. There is also a stand-alone supplementary note function and a Person in Charge review. The standalone supplementary note function should be completed as and when pertinent information needs to be captured, but does not fit into one of the 256 other interactions on the system. The Person in Charge review should be completed every shift, by the person in charge, for each resident in their care. The Person in Charge review must be toggled on for every resident.”
37. Mrs X says that both the physical and psychological impact of his stay at the care home were profound. She says “It took approximately 16 months before (he) could even consider another respite placement, and even then he was highly anxious and fearful, requiring extensive reassurance and support from professionals and family”.

Analysis

38. Despite the regulatory requirement to do so, the care provider failed to keep an “accurate, complete and contemporaneous record” of the care provided to Mr X. As a result it is not possible to accept all the assertions the care provider gives about Mr X’s fluid intake. Given the description of his poor condition on arrival home, corroborated by the carer and nurse who attended him and prescribed antibiotics, the likelihood is that he was not given the level of fluids which had been specified. That is a potential breach of the regulations and was fault which caused Mr X some significant injustice.
39. There is no evidence that Mr X was hoisted onto the commode, dressed before late morning or offered a shower while he was at the care home despite the specific requests made at the pre-admission assessment and recorded on his care plan. The report of how he was dressed when his daughter collected him show his dignity was not respected – and if he was dressed inappropriately then, when a family member was known to be arriving, it casts doubt on his presentation at other times. That was a further potential breach of regulations and caused Mr X considerable injustice. What should have been an enjoyable period of respite for him impacted significantly on his dignity and his sense of happiness during that time.
40. It is not sufficient for the care provider to assert that Mr X was able to request support, as though that excuses its shortcomings. It does not. Mr X was paying for a service which fell far short of what he expected to receive. In my view a “goodwill” payment of £500 is insufficient to rectify that.

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Action

41. The care provider has already sent me details of its new recording system so I make no further recommendations in that respect.
42. Within one month of my final decision the care provider should send details to me of the additional training it says its staff have taken in respect of record keeping, and of tissue viability recognition and monitoring.
43. Within one month of my final decision the care provider should offer Mr X a 50% refund of the fees paid for the respite period.
44. Within one month of my final decision the care provider should offer Mr X £500 which recognises the harm caused to Mr X in terms of the severity of the pressure sores which continued after he left the placement;
45. Within one month of my final decision the care provider should also reiterate its offer of £500 payment to Mr X to acknowledge the distress its actions caused. In addition it should make a payment of £500 to Mrs X to recognise the distress caused to her and the time and trouble she was put to in pursuing this complaint.
46. The Care Provider should provide us with evidence it has complied with the above actions.

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Investigator's decision on behalf of the Ombudsman