Summary: The complainant, acting on behalf of her late father, has raised several issues with the standards of care he was provided during his stay in a nursing home, which was commissioned jointly by the Council and by the NHS. We have found fault, which in some cases caused an injustice, and the Council and Care Provider have agreed to remedy this injustice and work to prevent a recurrence.

The complaint

1. I will refer to the complainant as Mr D. Mr D, who died in August 2020, is represented in his complaint by his daughter, to whom I will refer as Mrs W.
2. Mrs W complains about the care Mr D received in Milton Court Care Home (‘the Home’), which is owned and operated by Avery Homes Ltd (‘the Care Provider’). Mr D’s stay in the Home was commissioned partly by Surrey County Council, and partly by the local Clinical Commissioning Group.
3. In particular, she says:

1. in January 2020, Mr D contracted a urinary tract infection (UTI), but staff at the Home failed to recognise the symptoms of this, and Mrs W had to obtain medication for him herself;
2. in May 2020, Mr D contracted another UTI and also pneumonia, but staff again failed to recognise the signs he was deteriorating. As a result, Mr D had to be admitted to hospital, where he was found to be critically unwell;
3. the Home covered up the fact Mr D had suffered serious pressures sores in its care; and
4. that the Home failed to make adequate arrangements for contact between residents and their families during the COVID-19 lockdown.

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The Ombudsmen’s role and powers

4. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
5. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
6. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

7. I reviewed:

• Mrs W’s complaint correspondence with the Home;
• Mr D’s daily care notes;
• Mr D’s medication records;
• Mr D’s wound records;
• Mr D’s fluid intake records;
• Mr D’s hospital records, including its discharge summary; and
• comments made by the Council in response to my enquiries.

8. I also shared a draft copy of this decision with each party for their comments.

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What I found

9. Mr D was historically resident in the Surrey area. After a stay in hospital, it was agreed that Mr D should be admitted to residential care, as he was no longer able to care for himself at home.
10. Both of Mr D’s daughters, Mrs W and her sister (Mrs J), live in the Milton Keynes area. For this reason, the Council commissioned an ‘out of area’ placement at Milton Court Care Home in October 2016. Mr D remained at the Home until he passed away in August 2020.
11. For most of Mr D’s stay at the Home, his fees were paid by contributions from the Council, the CCG (under the Funded Nursing Care [FNC] scheme), Mr D himself, and a third-party top-up from his family. However, when Mr D returned to the Home from a stay in hospital in June 2020, the funding was provided entirely by the CCG under the Continuing Healthcare (CHC) scheme. The CHC funding remained in place until his death in August.
12. Although Mr D’s placement was originally commissioned by the Council, both the FNC and CHC funding schemes are administered by the NHS. Mrs W’s complaint therefore falls into the jurisdiction of both the Local Government and Social Care Ombudsman (LGSCO), and the Parliamentary and Health Service Ombudsman (PHSO). For this reason, we have decided to investigate this complaint under our joint working protocol.
13. In September 2020, after Mr D had passed away, Mrs W submitted a long letter of complaint to the Home. In her letter, she raised numerous and very detailed points of complaint about the standards of care Mr D had received in the years since his arrival at the Home, and about the conduct of certain members of staff. When she remained dissatisfied with the Home’s response to her complaint, Mrs W referred it to the Ombudsmen on 28 January 2021.
14. The law says a complainant should approach both Ombudsmen within 12 months of becoming aware of the substantive issue they wish to complain about. Any incidents which pre-dated January 2020 – 12 months before Mrs W made her complaint to us – are therefore late.
15. In addition to this, many of Mrs W’s points of complaint relate to an alleged general failure by the Home to adhere to the proper standards, over an extended period of time. However, we normally consider such complaints to be better addressed by the Care Quality Commission (CQC).
16. The CQC is the statutory regulator for health and social care services in England; its role includes carrying out inspections of health and care providers, ensuring their services are to the required standards, and taking enforcement action where it finds they are not. In serious cases this can include prosecution.
17. In contrast, the Ombudsmen’s role is to investigate specific instances of administrative failure by bodies in their respective jurisdictions; and, where this has caused an injustice to the complainant in question, to recommend steps the body should take to put this right. Neither Ombudsman has the power of enforcement.
18. I have therefore agreed with Mrs W to narrow her complaint down to the four specific, and in-time, points I have defined at paragraph 1.
19. As I have said, Mrs W’s complaint to the Home is lengthy and very detailed, as are the Home’s responses. I will now seek to set out each party’s respective positions on the complaint, but, for the sake of clarity and brevity, I will only describe Mrs W’s comments, and the Home’s responses, on the four points of complaint I am investigating.
20. In her complaint to the Home, Mrs W said she had become concerned Mr D might be suffering a UTI in mid-January 2020. Early on 25 January, she visited Mr D, to find him drowsy and with a tremor in both hands. She visited again in the evening, to find he had eaten little during the day and appearing unwell. Mrs W said she decided to call the NHS non-emergency helpline (111) at that point.
21. Mrs W said she spoke to a doctor early on 26 January, who prescribed antibiotics for Mr D and told Mrs W she could collect them. After doing so, Mrs W took the antibiotics to the Home, but the duty staff member refused to administer them to Mr D because "she could not verify they were genuine”. Mrs W said the staff member insisted on speaking to a manager first, but the manager in question later told her she had not contacted him.
22. Mrs W has confirmed to me the Home later began administering the antibiotics to Mr D.
23. Mrs W then complained that, on 24 May 2020, the Home left messages for her sister, Mrs J, asking her to call back urgently. This was because a nurse had attended the Home to see Mr D and confirmed he was unwell. Mrs W questioned why the Home had not tried to contact her, given both she and Mrs J were recorded as Mrs D’s emergency contacts.
24. Mrs J later received a call direct from the nurse. The nurse asked her permission to call 999 for an ambulance for Mr D, because he was showing three “red flags” for sepsis. Mrs J agreed and Mr D was taken to hospital as an emergency, where he was found to have both a UTI and a chest infection. Mrs W said the doctor told her a urine sample taken by the Home on 15 May showed an infection, and she complained the Home had not informed her or Mrs J it had sent a urine sample to the hospital.
25. Mrs W said the hospital described Mr D as “extremely unwell and very dehydrated”, and that “his kidneys were on the verge of failing”. She asked how the Home could have allowed Mr D to deteriorate in this manner.
26. With regard to Mrs W’s complaint about Mr D’s pressure sore, she said she had received a message from the Home on 17 June informing her a sore had developed on Mr D’s right heel. The Home said it had made a complaint against the hospital, as Mr D had returned from there with it present. However, Mrs W said the hospital’s notes did not record a pressure sore while Mr D had been there.
27. Mrs W commented she had previously explained to the Home that Mr D had a condition which made him vulnerable to a particularly painful type of pressure sore. She referred to a previous sore Mr D had developed, and that she had had to intervene for staff to give him adequate pain relief.
28. Mrs W went on to say a tissue viability nurse (TVN) had visited Mr D on 27 July. She had then visited him herself the following day, in her own capacity as a medical professional. She said the TVN had dressed Mr D’s heel so she could not inspect the wound herself, but was “shocked” to see how much he had declined since her previous visit five weeks before.
29. Mrs W said the Home provided a copy of the TVN report, which had highlighted “serious mistakes” by staff in managing Mr D’s risk of pressure sores. This included that his specialist pressure relieving mattress had been on the wrong setting, and a failure to properly use a ‘squab’ (a special type of cushion) to relieve pressure on Mr D’s feet. Mrs W also complained neither she nor Mrs J had been informed Mr D now needed very strong pain relief simply to undergo personal care or wound care.
30. On the matter of lockdown contact arrangements, Mrs W said the Home had contacted relatives at the beginning of lockdown to explain that video calling would be available to allow “regular” contact with residents. However, the family had only had a “handful” of video calls with Mr D, and the Home sometimes postponed pre-arranged calls or failed to make them at all. Mrs W questioned the Home’s claim to have met the CQC requirement for having an adequate system of contact arrangements.
31. The Home wrote a letter of response to Mrs W’s complaint on 10 November.
32. With regard to the January 2020 incident, the Home said its records showed it had always promptly referred Mr D to the GP when he showed signs of infection. It apologised if Mrs W felt she had been unable to speak to staff on this occasion, but said it was good practice for staff to speak to the prescribing doctor before administering medicine to a resident.
33. The Home questioned how, in this case, a doctor had come to prescribe Mr D with antibiotics without first seeing him, which was a breach of the relevant guidelines. It said staff are unable to administer medicine without proper direction from a doctor, and considered they had acted appropriately by first seeking advice in this instance.
34. The Home noted Mrs W’s comments about Mr D being dehydrated on his admission to hospital in May 2020. It explained its records of his fluid intake prior to admission, and that it had taken a urine sample, but the hospital had reported the result to the wrong GP surgery.
35. The Home said the hospital records showed Mr D had been diagnosed with an acute kidney injury upon admission. He was later also diagnosed with a respiratory tract infection and a UTI, which were “clearly hospital acquired”. The hospital had been unable to establish the cause of the UTI, but the Home speculated Mr D might have become an E. Coli carrier which would explain the repeat infections. The Home noted that, during this stay in hospital, it had been agreed it was not in Mr D’s best interests to be admitted to hospital again in future.
36. On Mrs W’s complaint about pressure sores, the Home said a relevant care plan and risk assessment had been in place for Mr D since 2017, and that he had had the highest grade of pressure relieving mattress since 2018. Staff had checked this regularly to ensure it was in working order.
37. The Home said it had followed the TVN advice in ensuring Mr D’s heels were offloaded, and that his file included multiple photographs of the relevant areas. It noted there were records of abrasions to Mr D’s buttock from July 2020, but these appeared to be result of him scratching the area and not a pressure sore.
38. The Home went on to say its records showed Mr D’s heel “remained vulnerable but intact” until the end of May. Upon his return from hospital on 2 June, there was evidence he had suffered stage 2 pressure damage during his stay. This had deteriorated further by 12 June, at which point staff had contacted Mrs J and made a TVN referral. They recorded that they had continued to offload Mr D’s heels and reposition him, while noting he was very frail.
39. The Home noted the TVN had changed Mr D’s mattress setting from ‘medium’ to ‘soft’, but said ‘medium’ had been the correct setting for Mr D’s weight. However, it acknowledged his squab had been placed incorrectly and apologised for this. The Home said the TVN had asked Mr D whether he was suffering any pain, but he said not, and for this reason the nurse had prescribed only palliative wound dressings.
40. With regard to the complaint about contact arrangements, the Home said staff had worked hard to maximise the amount of contact time available for residents via mobile devices, but acknowledged this was not at the same level as it normally would be. It said a manager had taken the time to update Mrs W on a regular basis, and that nurses and the GP had also been in contact with Mrs J.
41. The Home said it was satisfied Mr D had had several video calls with family members, although it acknowledged again these were not a real substitute for face-to-face visits. However, it said it had had to balance the availability of staff and mobile devices.
42. Mrs W wrote a response to the Home on 13 November.
43. On her complaint about the January 2020 incident, she said she had spoken to an out-of-hours GP, who had reviewed Mr D’s medical history. Mrs W said the GP had decided it was in Mr D’s interests to undergo a course of antibiotics in order to avoid a hospital admission.
44. On the May 2020 incident, Mrs W wrote that, although Mr D’s fluid intake may have been “adequate”, the Home had not taken into consideration the dehydrating effects of the weather at the time. She said the hospital would not have put Mr D on fluids if he had not been dehydrated, as this would potentially have been dangerous.
45. Mrs W also said that, shortly after Mr D’s admission, the hospital had called her and said he was suffering both a UTI and a chest infection.
46. With regard to her complaint about pressure sores, Mrs W questioned why the Home had not provided copies of the photos on Mr D’s file, despite her requests for them. She noted the Home’s comment that Mr D’s heels had remained intact until the end of May, but questioned how it could know this when he had been hospital at that time. She reiterated the hospital’s records showed no evidence he had developed pressure sores during his admission, and commented that Mr D had been back at the Home for more than a week before staff there had raised concerns about Mr D’s heels.
47. Mrs W acknowledged Mr D may not have expressed pain to the TVN during their visit, but said this was because he was on strong painkillers at the time. She also commented that it had only been at her insistence the Home had prescribed these painkillers, when staff should have known how painful Mr D’s sores would have been.
48. Mrs W rejected the Home’s apology for the incorrect positioning of Mr D’s squab. She said this failure had contributed to development of Mr D’s pressures sores, including “the catastrophic wound which was the catalyst to [Mr D’s death].”
49. On the subject of lockdown contact restrictions, Mrs W said she considered it was reasonable to have expected the Home to facilitate a video or phone call between Mr D and his family at least once a fortnight, but had not even received this. She acknowledged and said she was grateful the Home’s manager had spent time speaking to her, but this was only after Mr D had begun to deteriorate after his return from hospital.
50. The Home responded in turn on 7 December, but reiterated its previous comments on Mrs W’s complaints.
51. Mrs W then referred her complaint to the LGSCO on 2 February 2021. With her permission, we subsequently opened a joint working case with the PHSO.

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Legislative background

Fundamental Standards of Care

52. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards which care must never fall below.

Hydration and nutrition

53. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 sets out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) has issued ‘Essential Standards of Quality and Safety’ as guidance on the outcomes adult social care providers should achieve.
54. The Essential Standards contain outcomes for each regulation. These outcomes detail what providers should be doing to meet the requirements of each Regulation.
55. Outcome 5 addresses meeting nutritional needs. It requires that people are encouraged and supported to have sufficient food and drink that is nutritional and balanced, and a choice of food and drink to meet their different needs (Regulation 14).

Medication records in nursing homes

56. The Medication Administration Record (MAR) sheet lists a patient’s medication, the quantity of tablets received, the dose, frequency and time of administration over a four-week period. The pharmacy or GP surgeries usually print the MAR. Home staff sign it acknowledge receipt of medication, to record when they administer it or to record if, for any reason, it is not given.

Staffing levels

57. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 (Part 4, Section 22) places a responsibility on service providers to ‘take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced persons employed’ to provide the service in question. However, there are no mandatory rules for service providers setting out what constitutes a sufficient level of qualified staff. This is a decision that is ordinarily made at local level (such as by a care home or hospital), taking into account the level and acuity of the needs of the patients or residents in that facility.
58. The Care Quality Commission (CQC) is the independent regulator for health and social care services in England. In this capacity, the CQC is the agency best placed to consider whether a care home has appropriate staffing resources in place in general terms.

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Analysis

59. I will address each of the four agreed points of complaint in turn.

The January 2020 incident

60. Mrs W complains staff at the Home failed to identify signs Mr D was suffering an infection in January 2020. She also criticises staff for delaying the administration to Mr D of antibiotics she obtained for him.
61. I have reviewed Mr D’s care notes for the period in question. In the days before the incident, staff consistently recorded that Mr D was “settled”, and eating and drinking well. There is no indication of any change in Mr D’s condition until the morning of 25 January.
62. At this point, the notes record that Mr D’s temperature was 36.2oc, after Mrs W had asked staff to take it. Several hours later, a staff member commented that Mr D had been “very tired today”. Shortly after this, a different staff member recorded they had applied a ‘Newcastle pad’ (a type of incontinence pad which allows a urine sample to be taken), while noting Mr D was alert and smiling.
63. The notes then record Mrs J arrived to visit Mr D, and asked for his blood pressure to be taken because he was “sleepy”. The notes say Mrs J was satisfied with the result of the blood pressure measurement, but also alerted staff Mr D’s Newcastle pad had been contaminated with faeces. Mr D later had his temperature taken again, which was 36.4oc. The notes say staff were to try again to collect a urine sample.
64. A note entered at 2250hrs says:

“At around 21H00 I got a call, the caller identified herself as a ‘111 nurse’ and she asked if she could speak [Mr D’s] daughter … [Mr D’s] daughter later told me that a 111 doctor will be coming to see [him]. She went on to express how concerned she was about her father and how his current clinical picture was similar to when he was hospitalised a “few weeks ago”. Despite evidence to the contrary she expressed that her father had not had adequate fluids. I informed her that, according to the handover, [Mr D] was much brighter than he was the previous night.”

65. Then, at 0130hrs on 26 January:

“I received a call from a Dr [name] (out of hrs) who wanted know how [Mr D] was. He was informed that [Mr D] was comfortable in bed and that his urine was positive of leucocytes protein and blood. [Mr D] has been put on Augmentin and his daughter is aware of this and will be picking up the script from [illegible] tomorrow morning. [Mr D] remains stable.”

66. At 1100hrs, a note records Mrs W’s arrival at the home. It says:

“[Mrs W] said to [staff member] that she has antibiotics for [Mr D] which need to be kept in the fridge and started as soon as possible … [Staff member] collected the antibiotics, I contacted [manager] to explain to him about yesterday’s event and what had just taken place, and to seek his advice on the matter. [Manager] told me to contact 111 and ask for a written confirmation to be sent via fax regarding the antibiotics.”

67. There were then a number of phone calls back and forth between the Home and a doctor, with written confirmation recorded as being received at 1227hrs. The notes then say the Home began to administer the antibiotics to Mr D at 1300hrs.
68. In response to my enquiries, the Council made some additional comments about this incident. It says Mrs W believed Mr D had developed a UTI after her visit on 25 January, “but did not discuss this with the home team”. The following day, she arrived there with the antibiotics, but the Home could not accept them because no indication of infection had been seen and “no tests undertaken”. The Council also said the out-of-hours 111 service had not contacted the Home or sought any information before prescribing the antibiotics.
69. I note, first, there is some contradiction between this and the Home’s records. In particular, it is evident the Home had received contact from 111, both late on 25 January and in the early hours of 26 January. The nurse and doctor who made these respective calls enquired about Mr D’s presentation, and the doctor informed the Home he had prescribed antibiotics (Augmentin) and that Mr D’s “daughter” would be collecting them in the morning.
70. The Home’s notes also show a urine test had been undertaken, which showed the presence of leucocyte protein and blood (both potential signs of infection), and that it informed the 111 doctor of this. This conflicts with the Council’s comments that Mr D had not undergone any tests.
71. Mrs W has also provided copies of Mr D’s medical records. I note, in particular, the 111 doctor’s note of the call with the Home at approximately 1am on 26 January, which states “confirmed UTI”. This appears to be the doctor’s interpretation of the result of Mr D’s urine test. The evidence therefore appears to confirm Mr D had developed a UTI.
72. However, this does not automatically mean I can find fault staff did not identify this. As I have said, although staff had noted Mr D appeared unusually sleepy during the day of 25 January, the records indicate he was otherwise content, and there appears to have been nothing abnormal about his temperature or blood pressure. While, in hindsight, there are reasons to believe Mr D’s sleepiness may have been a symptom of his infection, I cannot say staff should reasonably have recognised this sooner.
73. I am also conscious these events all took place in a relatively short period of time – a little over 24 hours. Mrs W first raised concerns in the morning of 25 January, and a few hours later, staff applied a Newcastle pad to Mr D in an attempt to take a urine sample (albeit they were unsuccessful at this time). While it could be argued the pad should have been applied immediately after Mrs W raised concerns, I do not consider a few hours’ delay to be significant.
74. Taking this together, I cannot say staff were at fault for failing to identify signs of infection. This is not to say there definitely were no such signs, or that staff definitely did not miss them, but simply that I cannot draw these conclusions even on balance of probabilities on the evidence which is available to me. The care notes over the period, while difficult to read in places, appear reasonably comprehensive, and there is nothing to suggest staff would have failed to record any clear and drastic changes in Mr D’s condition, if they had observed them.
75. I will now turn to Mrs W’s complaint the Home did not immediately begin to administer the antibiotics she had obtained for Mr D.
76. On the basic level, I accept – as both the Home and Council have said – it would not be appropriate for staff to simply accept medication for a resident without formal confirmation it was appropriate. I understand Mrs W is herself a medical professional, but she is not a doctor, and so it would not be unreasonable for the Home to question the source of medication under these circumstances.
77. In this instance, however, the evidence shows Mrs W did not simply turn up ‘out of the blue’ with the antibiotics for Mr D. The Home’s own records of the call from 111 doctor show it was aware he had prescribed medication for Mr D, and that this was to be collected in the morning by one his daughters. Unfortunately the note does not explain whether the doctor was referring to Mrs W or Mrs J here, but from context, I assume he meant Mrs W.
78. So it is difficult to reconcile this with the apparent surprise of staff at Mrs W’s arrival with the prescribed medicine some 9-10 hours later.
79. I still recognise staff could reasonably wish to obtain written confirmation direct from the doctor before administering the medicine to Mr D – for the purposes of comprehensive record-keeping, if nothing else. I do not consider this, in itself, to be fault. But even accepting this, I must question why staff did not request written confirmation from the doctor when he called the Home in the early hours of 26 January, rather than waiting until Mrs W arrived. This would have helped reduce the confusion later on.
80. Either way, I am again conscious of the limited timeframe here. The notes show Mrs W arrived at 1100hrs, and that staff began to administer the medicine to Mr D at 1300hrs, only two hours later. This does not appear to be a significant delay in the context.
81. Given the – seemingly unnecessary – confusion about the medicine, I am satisfied there was some limited fault by the Home here. However, due to its brevity, I do not consider the consequent delay in administering the medicine to Mr D represents a significant injustice to him.
82. I find fault, which did not cause injustice, to Mr D in this element of the complaint.

The May 2020 incident

The May 2020 incident

83. Mrs W complains that Mr D developed another UTI and a chest infection in May 2020, and that the Home again failed to identify the signs of deterioration. This led to Mr D being admitted to hospital on 24 May, where he was found to be gravely ill.
84. I have again reviewed Mr D’s care notes for the relevant period. On 14 May, staff recorded Mr D appeared sleepy, and on the following day, they took a urine sample for the hospital.
85. On 22 May, a member of staff called Mr D’s GP surgery to follow-up the result of the urine test, but the surgery said it had not received anything. Later on the same day, staff again noted Mr D appeared sleepy.
86. There are further references to Mr D being sleepy over the next couple of days, and then, just after midday on 24 May, staff recorded he was wheezing. Shortly after this a member of staff called the local NHS rapid response team, and a nurse arranged to visit the Home to assess Mr D later that day. In the meantime, the Home recorded the results of some observations they had made, and that they had called Mr D’s “daughter” (from Mrs W’s comments, this appears to mean Mrs J) and left a voicemail for her. Unfortunately, these notes are, in places, difficult to read.
87. The notes then record the nurse arrived at approximately 1600hrs and assessed Mr D. This note, in particular, is very difficult to read. However, it is possible to make out references to ‘sepsis’ and the need for ‘further investigations’. I interpret this to mean the nurse had identified possible signs of sepsis, and had recommended Mr D go to hospital, which is consistent with the rest of the evidence.
88. Mrs W again considers the Home failed to identify Mr D’s signs of deterioration. In contrast, the Council has pointed out the Home took a urine sample some time before Mr D’s hospital admission. Unfortunately, as it later transpired, the hospital sent the results to the wrong GP surgery. Both Home and hospital were responsible for checking and maintaining up-to-date records; and so, on the evidence, I cannot say where the responsibility for this error lies.
89. Either way, I am concerned the Home appears to have waited until 22 May – more than a week later – to chase up the result of Mr D’s urine test. And, when it became apparent Mr D’s GP had not received the result, I would expect the Home to consider contacting the hospital direct. Had it done so, the hospital’s mistake may have become apparent sooner.
90. I am also conscious the Home’s notes do not appear to indicate any deterioration in Mr D’s condition between 14 May, when he was observed to be sleepy, and 24 May, when his wheeziness was noted. Given he was ill enough to need an emergency hospital admission by 24 May, it is difficult to imagine he did not show any other signs of deterioration before then.
91. But, beyond speculation, I cannot say this amounts to evidence of fault. Although, as I have said, the Home’s notes are illegible in places, for the most part they appear comprehensive. They do not generally leave me with the impression staff may have missed, or failed to record, any obvious signs of distress or unwellness in Mr D. And I am satisfied that staff responded quickly on both occasions they observed potential symptoms of infection.
92. Therefore, while, in hindsight, it appears clear Mr D must have been deteriorating between 14 and 24 May, this does not mean staff were failing to properly observe or note his symptoms.
93. For the same reason, I cannot say staff should have sought medical intervention earlier than 24 May. I acknowledge Mrs W says Mr D was critically ill when he arrived at the hospital, and, while I cannot make any judgement on this myself, I do not dismiss this comment. But I am bound to make a judgement on the objective evidence available to me, and this shows staff responded appropriately to Mr D’s condition as it appeared at the time.
94. I still maintain my criticism the Home did not chase up the result of Mr D’s urine test before 22 May, for the reasons I have given. However, even accepting this, it is again speculation to say this would have made any material difference to Mr D’s situation. It does not mean, for example, he would have been admitted to hospital any sooner than 24 May.
95. Mrs W also complains the Home did not inform her or Mrs J that it had taken a urine sample on 15 May. I have seen no evidence to contradict this and so I am satisfied, on the balance of probabilities, it is true. But, with respect to Mr D’s care, I cannot perceive any particular consequences to this. And while I acknowledge why Mrs W would be dissatisfied the Home failed to pass on this information, taking everything together I do not consider this is a significant point.
96. There is also disagreement between Mrs W and the Home about Mr D’s diagnosis upon admission to hospital – specifically, whether he had a UTI and chest infection, and whether he was dehydrated.
97. In its response to my enquiries, the Council said:

“The discharge summary documents that [Mr D] was admitted and treated for acute kidney injury and lower respiratory tract infection (LRTI). He was noted to have contracted a hospital acquired UTI on completion of his treatment for the LRTI.”

98. I have reviewed a copy of the discharge summary provided by the Council. Under ‘diagnosis’, the summary records three confirmed conditions. As the Council says, these are: (1) an ‘acute kidney injury stage 1’; (2) a lower respiratory tract infection; and (3) a urinary tract infection.
99. The summary also says that condition 1 presented on 24 May, while conditions (2) and (3) both presented on 1 June. The implication of this is that, when Mr D arrived at the hospital on 24 May, he was suffering from a kidney injury. By the time he came to leave hospital, it had also been confirmed he was suffering an LRTI and a UTI.
100. So this in fact slightly contradicts the Council’s comments, in that it was not only the UTI which was not ‘presenting’ at the time of Mr D’s hospital admission, but also the LRTI. Either way, this information implies that Mr D acquired both infections during his stay in hospital.
101. However, I have also reviewed the hospital records provided by Mrs W. The hospital’s notes of 24 May record Mr D had been screened for sepsis, with the comment “known sepsis with appropriate treatment” and that this was a “UTI”. They also comment Mr D had symptoms suggestive of a chest infection, and that the ‘impression’ was that these were “nursing home acquired”.
102. I note Mrs W says the hospital called her shortly after Mr D’s admission and confirmed he had both a chest infection and UTI. The hospital’s notes also record a conversation with Mrs W on 25 May, where it explained to her Mr D had a chest infection, although it was still waiting for the results of a urine test at the time.
103. And another note of 26 May refers to Mr D receiving treatment for both types of infection.
104. There is, therefore, a conflict in this evidence. The Council has pointed out the discharge summary shows Mr D acquired both LRTI and UTI in hospital, and I accept entirely this is how it must (logically) be read. But the hospital’s notes indicate very strongly Mr D had both conditions on admission.
105. Having said this, it is also apparent the copy of the hospital records Mrs W has provided is incomplete, and so I cannot comprehensively review the notes made while Mr D was there.
106. However, given the hospital records’ much greater detail, I consider they carry more weight as evidence. On the balance of probabilities, I will assume the dates listed on the discharge summary are incorrect.
107. But the implications of this for Mrs W’s complaint against the Home are less obvious. Even accepting Mr D developed both infections while he was the Home, this again does not mean staff failed to perform their duties adequately. It is unfortunately the case that nursing and care home residents may acquire infections, no matter how well their care is managed.
108. With regard to dehydration, Mrs W has said Mr D was severely dehydrated on admission to hospital, to the point his kidneys were nearly failing. In response, the Home has pointed out Mr D’s fluid intake was normal in the run-up to his hospitalisation.
109. I have reviewed the Mr D’s fluid intake records, and again his care notes. As the Home says, there does not appear anything unusual about Mr D’s fluid intake during the relevant period. Staff would provide him a range of drinks through the day, and, if he awoke, at night. In most cases, the records show Mr D would accept all he was offered, but on occasion he would leave some undrunk.
110. I acknowledge the point Mrs W has made, that the hospital would not have put Mr D on fluids if he had not required it; but I am not persuaded the hospital records support that he was ‘severely’ dehydrated upon admission. For example, on 25 May, the notes record the hospital had told Mrs W he was now on IV fluids, and on 26 May, that it was “giving [Mr D] IV fluids as he is a bit dehydrated and not taking much fluids orally” (emphasis my own).
111. While the hospital records clearly do evidence some dehydration in Mr D, there is nothing which clearly supports Mrs W’s statements of its severity.
112. I also acknowledge Mrs W’s point, that Mr D’s fluid intake was not the only factor to consider when determining whether he was dehydrated. However, I cannot overlook that the Home’s records show he declined some of the drinks staff provided for him; and that this appears consistent with the hospital’s comment about Mr D’s unwillingness to drink. This suggests Mr D’s dehydration may have been the result of his being unwell, rather than a failure by staff to provide him with adequate care.
113. Taking this all together, I find fault by the Home in failing to follow up the result of Mr D’s urine test sooner than 22 May, but I do not consider there is evidence this caused Mr D a significant injustice.
114. I find fault, which did not cause injustice, in this element of the complaint.

Pressure sores

115. Mrs W complains Mr D developed pressure sores at the Home, and that staff’s failure to properly place his squab bears some responsibility for this. She also accuses the Home of ‘covering up’ the development and extent of Mr D’s pressure sores.
116. Pressure sores (also called ‘pressure ulcers’) can arise when a person remains in a seated or lying position for extended periods of time, for example where they are bed- and/or wheelchair-bound. They are caused by a loss of blood flow to parts of the body in constant contact with a firm surface like a mattress.
117. Sores are generally graded (or ‘staged’) 1 to 4, according to their severity:

Grade 1 – skin intact but reddened

Grade 2 – an open but shallow sore or blister

Grade 3 – a sore penetrating fully through the skin into underlying tissue

Grade 4 – a sore penetrating underlying tissue, with possible exposure of bones and muscles

118. A sore may also be described as ‘unstageable’, where its depth cannot be conclusively identified.
119. I will also note here that, in this context, a ‘squab’ refers to a particular type of pillow.
120. Mr D’s wound records document the identification and treatment of several different injuries he sustained during 2020. These included pressure sores on both ankles and one shin, along with a range of other wounds described variously as abrasions, scratches and bruises.
121. For the purposes of my investigation, I will consider only the three confirmed pressure sores. The following summarises the key points from Mr D’s records.
122. On 14 January, the Home noted Mr D had developed “some redness” on his left heel, and that it was taking steps to prevent deterioration. On 28 January, the Home contacted a tissue viability nurse for advice. The TVN said her team had already given its recommendation for this, and that it would not visit for “a category 2 skin about [Mr D’s] heel [sic]”. The Home’s manager then checked for an email containing the recommendation from the TVN team, but could not find one, and said he would follow it up with the team.
123. There are occasional further notes on Mr D’s left heel between January and May. The notes record Mr D’s heel remained vulnerable, but intact, and that staff moisturised it daily.
124. Then, on 16 June (approximately a fortnight after Mr D’s return from hospital), the Home noted the left heel had become “very dry” and red. Staff cleaned and applied cream, then ‘offloaded’ the heel. They made similar records over the following weeks; and, on 25 June, noted there was a “small black area” on the heel.
125. The last note is from 28 June. It again records Mr D’s heel as vulnerable, that staff took some steps to protect it, and offloaded it with “pillows and cushions”.
126. With regard to Mr D’s right heel, the Home’s notes also start on 14 January, where it is recorded he had developed a grade 2 pressure sore on his right heel.
127. I can see no more notes about Mr D’s right heel until 16 June, when it was recorded he had now developed a grade 3 sore there. The notes say the Home had made a referral to the TVN team, and outlined a care plan for Mr D’s heel in the meantime.
128. The notes also include a copy of an email sent by a TVN the following day. She confirmed, having reviewed photographs sent by the Home, that the sore appeared to be grade 3. The nurse wrote:

“It is important to establish where this pressure ulcer deteriorated as I understand we gave advice for the same heel in January 2020 and it was category 2. Is this hospital acquired damage or did this occur whilst in your care? A safeguard [sic] and notification to CQC is required.”

129. She then gave the Home further advice on how to manage the pressure sore.
130. The records provided by the Council also include an extensive note of a visit to Mr D on 27 July by a medical professional. It is unclear exactly who this professional was, but from context, it appears to have been a TVN.
131. The note records a diagnosis of ‘ischaemic right leg’, and that the nurse advised the Home to ‘upgrade’ Mr D’s pressure mattress to “low air loss so [he] more immersed as extremely vulnerable to pressure”. The meaning of this is somewhat unclear, but to my interpretation, the nurse was advising the Home to reduce the pressure setting on Mr D’s mattress, so that it softened and allowed him to ‘sink’ into a little more.
132. The note describes Mr D as having an “unstageable” pressure sore to his right heel, and that staff were concerned about its rapid deterioration. It then says:

“pressure ulceration to right heel following discharge from hospital in June 20”.

133. But then, further on, that the sore:

“was originally sustained during hospital stay in June 2020”.

134. The note also says the nurse reduced Mr D’s mattress setting from ‘medium’ to ‘soft’, and that Mr D’s squab did not have any pressure-relieving qualities and should be moved from the foot to the head of his bed.
135. Separately, on 18 June, the Home recorded that Mr D had developed a grade 2 pressure sore on his left shin, and said this was because he had a “tendency” to lie with his legs crossed. I note Mrs W has commented Mr D had taken to crossing his legs to relieve the pressure on his right heel.
136. The notes set out steps for staff to take to manage this sore, including that they should place a pillow between Mr D’s knees to prevent him from crossing his legs.
137. Again, there are some notable inconsistencies in these records.
138. I first note the records show concerns were first raised about both of Mr D’s heels in January. But there does not appear to be any further note about Mr D’s right heel until after his return from hospital in June.
139. The records also show the Home sought advice about Mr D’s left heel from the TVN team in January (albeit the team responded it had already given advice, which the Home seemingly could not locate at the time). Later on, after the Home’s referral for Mr D’s right heel, the TVN expressed concern the Home may not have followed the advice it received in January.
140. It is difficult to escape the conclusion these contradictions arose from confusion between Mr D’s left and right heels, especially as there is no evidence the Home sought, or received, advice about the right heel in January. I cannot, however, explain the reason for this confusion.
141. Either way, it is not in dispute that, by mid-June, Mr D was suffering a significant pressure sore to his right heel.
142. There is once again a potential inconsistency in the records about this, with the TVN’s note of 27 July appearing to suggest the sore had developed both during, and after, Mr D’s stay in hospital.
143. Referring to the hospital’s own records, I can see several notes that Mr D’s heels (plural) were red, along with his “bottom” and sacrum (base of the spine). In particular, a note of 29 May says:

“Right heel has an old skin [sic] seems a blister and red blanching…”

144. It appears, therefore, the TVN’s note may have been seeking to explain there was an existing (albeit less developed) sore to Mr D’s right heel during his stay in hospital, but which had deteriorated since his return; although I cannot be certain this was the nurse’s intention.
145. I also cannot overlook the simple fact the first record of a grade 3 sore on Mr D’s right heel is dated 16 June, two weeks after he returned to the home (although I note, in its complaint response, the Home said its concern arose on 12 June). The Home’s records include photographs of several of Mr D’s wounds, and, while the copies I have are unfortunately not of particular high quality, it is obvious the right heel sore was extensive. Had Mr D returned from the hospital with this wound, it is difficult to see how the Home could fail to have noticed it sooner than 16 June, or even 12 June.
146. Taking these points together, and on the balance of probabilities, it appears Mr D had been suffering from a sore to his right heel for some time before his hospital admission, but that it only deteriorated to grade 3 after his return to the home.
147. This does not mean I am in a position to judge whether the Home can be held responsible for the deterioration of Mr D’s right heel, nor the development of his other sores. The records are clear, throughout, that he was particularly vulnerable to such injuries, and it is sadly not the case they can always be averted, no matter how well cared-for a person is. And it is not for me to decide whether Mr D’s wounds were avoidable or caused by poor care, as this is a matter of clinical judgement.
148. But there remain several points where I am satisfied the Home can be criticised here.
149. First, as I have observed, the Home sought advice from the TVN team in January, but the team said it had already provided advice. The Home’s notes said it could not locate this advice, and indicated a manager would contact the team again to enquire about this, but there is nothing further in the notes to show what happened.
150. It is possible the Home did follow up with the TVN team, and that it simply omitted to make a record of this. I note the Home made several notes between January and May, explaining how it was managing Mr D’s left heel, and this may have been the result of the TVN’s advice. But the steps the Home was taking to manage the sore were fairly general – for example, regularly moisturising it, encouraging him to eat and drink well, and keeping it offloaded – and so it is equally possible the Home had not followed up with TVN, and was simply using ‘common sense’ in the absence of any specialist advice. I cannot say which of these is true.
151. In addition to this, while the notes document the Home’s referral to the TVN team in January, they suggest this was only in relation to Mr D’s left heel. However, the Home’s notes also show Mr D had developed a sore to his right heel by January as well.
152. As I have already commented, it appears there may have been some confusion by the TVN team about whether the Home’s referral was about Mr D’s left or right heel. I must also consider the possibility the referral was in fact about both heels, but, if so, I would expect the Home’s notes to have made this clear.
153. More troublingly, and regardless of any confusion about the specifics of the referral, there is nothing in the notes to show the Home took any steps – at all – to manage Mr D’s right heel after identifying a sore there in January. The next note about Mr D’s right heel was in June, after it had developed to grade 3.
154. The implications of this are unclear. On a simple level, it could be read to mean the Home ignored the sore on Mr D’s right heel until after his return from hospital. This would be an extremely serious fault if so.
155. But equally, it could simply mean the Home failed to record what it was doing. Reviewing the management plan for Mr D’s left heel, there are several points which would evidently benefit both heels anyway – for example, keeping to a well-balanced diet, and offloading, for which the plan specifically refers to “heels” (plural).
156. So, taking this all together, I cannot say conclusively what the Home did in response to its identification of the sores on Mr D’s heels in January. There is evidence to show it understood the seriousness of the situation, and sought professional advice, which is positive. The evidence also shows it took at least some steps to manage the wounds.
157. But, even if the Home did respond appropriately throughout, the inconsistencies and gaps in its records still amount to fault.
158. The second issue here is the Home’s (admitted) failure to properly use Mr D’s squab.
159. It is difficult for me to understand the exact nature of this fault. Both Mrs W, and the Home, have referred to placing it in the wrong position; but I cannot see any specific explanation for what this means.
160. And I also note the TVN’s comments in July, that the squab should be moved from the foot of Mr D’s bed to the head, as it had no pressure-relieving qualities. This suggests the Home should not have been using the squab to deal with Mr D’s heel pressures sores at all, rather than simply that it had been using it wrongly.
161. On the evidence available to me, I do not consider I can say anything more conclusive than this. But given the Home’s admission, and apology to Mrs W, I must find fault on this element as well.
162. Third, during the visit in July, the TVN said Mr D’s pressure-relieving mattress should be set to ‘soft’, not ‘medium’, and her note records she had changed the setting accordingly. However, the Home has provided its record of the checks it carried out on Mr D’s mattress. These show the setting was always on ‘medium’, even after the TVN’s visit on 27 July.
163. I note the Home said, in its response to Mrs W’s complaint, that ‘medium’ was the correct setting on the mattress for someone of Mr D’s weight. I cannot say where the Home took this information from, but I accept there may be some form of guidance or instruction for Mr D’s mattress to support this. But, even if that is true, I can only conclude the Home simply disregarded the TVN’s advice and switched Mr D’s mattress setting back to ‘medium’ after her visit.
164. I am very critical of this. Tissue viability nurses are medical professionals, specialising in the prevention and management of precisely the injuries Mr D was suffering. This being the case, their advice should carry significant weight. This is not to say the Home had no right to question the advice, if it considered it was incorrect; but if so, it should have explored this further, for example with the TVN team itself, or by seeking the advice of a doctor. It should not simply have changed Mr D’s mattress back to its original setting. This was a significant fault.
165. It is unfortunately not easy to determine what injustice these faults could be said to have caused Mr D. First, and to reiterate, I cannot decide myself whether they caused Mr D’s pressures to develop or deteriorate, as these are matters of clinical judgement.
166. Second, while I have criticised the Home for its poor record-keeping, this obviously does not represent a direct injustice to Mr D, as it does not mean, in isolation, he was receiving poor care.
167. But it does mean I cannot make any conclusive findings on a significant point of complaint here, which I consider an injustice to Mr D in itself.
168. And, while the consequences of the issues with the squab and mattress are not for me to judge, the Home’s failure to use them properly can be said to have at least increased the risk to Mr D of the development, and deterioration, of his pressure sores.
169. I find fault causing injustice in this element of the complaint.

Contact arrangements

170. Mrs W complains the Home did not implement adequate arrangements to allow contact between residents and their loved ones during the first COVID-19 lockdown.
171. In response to this element of Mrs W’s complaint, the Council has provided a statement from the Care Provider. The statement says:

“Avery Healthcare has followed all UK Government (UK Gov) and Public Health England (PHE) guidance in relation to Care Home visiting during the COVID19 Pandemic.

“During the initial lockdown, visiting in homes was limited to essential visitors only … Residents and relatives were assisted to continue communications as much as possible through the use of telephone and video-calling. We also utilised social media platforms to (with permission) post pictures and videos of activity happening inside the home with individual residents. This was necessarily limited due to the isolation and social distancing regulations in place at the time.”

172. I understand Mrs W’s criticism of the Home is particularly focussed on the limited number of calls she and the rest of her family received from Mr D during lockdown. In her complaint to the Home, she said, based on the number of residents there at the start of the pandemic, it was reasonable to expect a video or phone call to be facilitated at least once a fortnight, but this was not what happened.
173. I do not seek, in any way, to dismiss Mrs W’s view here. On a basic level, to expect some form of contact with Mr D once every two weeks certainly does not strike me as excessively demanding, even under the acute strain of the early part of the pandemic.
174. But there is equally no practical test I can apply here, to decide whether the Home was at fault. While the Government issued detailed guidelines to care homes about the safe facilitation of contact between residents and their families, it did not set a threshold for how often people could expect contact to be allowed. This was a matter for the homes to manage as best they could, with the staffing and technology resources they had available.
175. This being so, I consider it most appropriate to discontinue this element of my investigation. I am not persuaded I will be able to make a meaningful or useful finding here.
176. I have discontinued my investigation of this element of the complaint.

Conclusions

177. I have found fault, which did not cause injustice, in the complaints about both the January 2020 and May 2020 incidents; and I have discontinued my investigation of the complaint about contact arrangements. I therefore make no recommendations in relation to these complaints.
178. I have found fault causing injustice in the complaint about pressure sores. This injustice was, first and foremost, to Mr D himself, but it is sadly not possible to remedy this now he has passed away.
179. However, I am also satisfied this injustice affects Mrs W herself, in the distress she suffered as Mr D’s next of kin. I will therefore recommend the offer of a symbolic financial remedy to Mrs W to reflect this.
180. In the course of her complaint, Mrs W has made two general observations about staff at the Home: first, that it is not adequately staffed for the number of residents; and second, that she believes several nursing staff are not registered with the Nursing and Midwifery Council (NMC), which is an offence. Mrs W says she has referred the Home to both the Care Quality Commission (CQC) and NMC as a result.
181. I will not comment on Mrs W’s allegation about nurse registration, except to say that the NMC is the appropriate body to investigate this.
182. On Mrs W’s allegation about staffing levels, I note the CQC inspected the Home in May 2021, and issued a report of its inspection in June. According to the report, the inspection was prompted by concerns it had received from whistle-blowers about understaffing at the Home.
183. And the report upheld this concern, saying:

“We have identified a breach in relation to their being insufficient staff to meet people's needs consistently, and in a timely way at this inspection.”

which I accept gives considerable weight to Mrs W’s allegation.

184. This does not mean, however, I can say any of the fault I have identified here is the consequence, direct or indirect, of inadequate staffing at the Home. It is quite possible that it is, but it is also possible other circumstances are to blame. My role in this matter is to identify fault by the Home, and seek to address its consequences, but I cannot determine the root causes of the fault.
185. But the CQC’s report is clearly both relevant and very timely, and for this reason I consider it bears comment here.

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Agreed action

186. Within one month of the date of my final decision, the Council and Care Provider have agreed to offer to pay Mrs W £300, to remedy the distress she suffered at the Home’s failure to properly manage Mr D’s pressure sores.
187. And, within three months of the date of my final decision, the Care Provider has agreed to review its pressure sore management protocols and procedures to ensure these reflect relevant national guidance. This should include specific guidance on the correct use of equipment in pressure sore management. The Care Provider should also consider what action it needs to take to ensure staff are familiar with the revised protocols, and appropriately trained to implement them. It should then provide the Ombudsman with a report on its review and action plan.

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Final decision

188. I have completed my investigation with a finding of fault causing injustice.

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Investigator's decision on behalf of the Ombudsman