Summary: Mrs B complains about nursing care provided to her mother Mrs C by the Nursing Home, about information the Council gave her about nursing home options, and how the Council handled a safeguarding referral. The Nursing Home has already taken some action to prevent recurrence, apologised to Mrs C and her family, and waived its fees. We found the Nursing Home did not keep detailed records about taking a urine sample, leaving Mrs B with uncertainty over what happened during this time. We also found the Council did not communicate clearly with Mrs B about safeguarding, and a delay in sending her the provider enquiry report. This meant Mrs B missed an opportunity to raise her concerns at the time. The Council and the Nursing Home have agreed to take action to address the injustice.

The complaint

1. Mrs B complains that Leeds City Council (the Council) gave her incorrect information about care home options when her mother, Mrs C, was discharged from hospital in January 2022. She also complains that Owlett Hall Nursing Home (the Nursing Home) offered by the Council, provided Mrs C with poor care. She said this led to Mrs C’s health deteriorating and her being admitted to hospital where a safeguarding referral was made. Mrs B also complains that the Council did not investigate properly when responding to the safeguarding referral. She said the provider enquiry report was inaccurate and had information missing. Mrs B also said the Council delayed providing her with a response about the safeguarding enquiry.
2. Mrs B said that because of these events, Mrs C did not receive the care she should have had. Mrs B said it was also an upsetting time for her and she has not received explanations for what happened.
3. As an outcome of her complaint to the Ombudsmen, Mrs B seeks explanations about the care provided to Mrs C before she went into hospital. She also wants the Nursing Home and the Council to improve their services so other people are not similarly affected.

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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. In investigating this complaint, I considered information Mrs B provided in writing and over the telephone. I considered the organisations’ responses to my enquiries, including Mrs C’s care records for the period complained of. I also took advice from one of PHSO’s clinical advisers, a registered nurse. I considered the law and guidance relevant to this complaint.
8. Mrs B, the Council and the Nursing Home had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Legislation and guidance relevant to this complaint

NHS Funded Nursing Care

9. NHS-funded nursing care (FNC) is the funding provided by the NHS to residential nursing homes that also provide care by registered nurses. FNC funding is set at a weekly rate.
10. The NHS is also responsible for meeting the cost of care provided by registered nurses to residents in all types of care homes. Council funded and self-funding residents who need to move into care homes with nursing should have a comprehensive assessment to identify any nursing needs, including the possible need for NHS-funded continuing healthcare (CHC) or for NHS-funded nursing care (FNC).
11. This complaint includes elements of nursing care which fall under the jurisdiction of the Health Service Ombudsman. Following the approach of the Health Service Ombudsman we consider the Nursing Home as provider of the nursing care to be the responsible organisation for the nursing elements of Mrs C’s care.

Fundamental Standards of Care

12. 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. The following regulations are relevant to Mrs B’s complaint:

• Regulation 17: Good Governance, says providers must securely maintain accurate, complete and detailed records in respect of each person using the service.

Nursing and Midwifery Council (NMC) Code of Professional Conduct

13. The NMC Code sets out the professional standards of practice and behaviour for nurses, midwives and nursing associates.

National Institute for Health and Care Excellence (NICE) guidance

14. NICE Clinical Guideline 103, Delirium: prevention, diagnosis and management in hospital and long-term care, is relevant to this complaint.

Safeguarding

15. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (Section 42, Care Act 2014)

What happened

16. In January 2022, Mrs C was in hospital and was ready to be discharged. Mrs C had previously lived in a care home. However, the previous care home was no longer able to meet Mrs C’s needs, so a new placement was needed.
17. The Council contacted Mrs B and discussed nursing home options with her. The Council contacted several nursing homes to try to find a place for Mrs C. Most of the homes contacted were full or could not meet Mrs C’s needs.
18. Mrs C left hospital under Discharge To Assess arrangements. This meant the NHS initially funded her care at the Nursing Home, until her healthcare needs were assessed. On 9 February, Mrs C was assessed and found to be eligible for NHS Funded Nursing Care (FNC).
19. On 17 February 2022, Mrs C attended A&E with symptoms of a urinary tract infection (UTI). Mrs C was prescribed antibiotics. The Hospital Trust asked the Nursing Home to take a further urine sample after Mrs C returned to the Nursing Home. However, a sample was not taken until 28 February. The next day, the Nursing Home arranged for Mrs C to go to hospital, where a safeguarding alert was raised. After leaving hospital, Mrs C moved to a different nursing home.
20. In March 2022, Mrs B emailed the Council and the Nursing Home with concerns about the care provided and the information the Council gave her about care homes. The Council opened a safeguarding enquiry in response to the concerns raised by Mrs B and the hospital trust. The Nursing Home also responded to the complaint about care. It responded to 17 issues, including Mrs C falling while at the Nursing Home, communication with the family, personal care, missing items of clothing, and delay in taking a urine sample. The Nursing Home upheld nine of the complaints raised, and partly upheld a further four. It apologised to Mrs C and her family, and waived the outstanding charges. However, Mrs B was dissatisfied with the response. She said she had not received an explanation for Mrs C’s deterioration before she went into hospital, or why a urine sample was not taken. The Council also responded to Mrs B about the information provided about nursing homes, and about the safeguarding enquiry. Mrs B was dissatisfied with the response from the Council, and she complained to the Ombudsmen.
21. As Mrs B has raised several issues within her complaint, I have set each of these out under separate headings, below.

Advice from the Council about nursing homes

22. Mrs B complained that when Mrs C was ready to leave hospital, the Council gave her incorrect advice about nursing homes. She said she did not receive a proper explanation of Discharge To Assess and CHC funding. Mrs B said that had the Council given her the correct information, Mrs C need not have received poor care, as Mrs B would have decided she would go to a different nursing home.
23. The Council acknowledged there was some confusion over arranging a placement, because of the way Mrs C’s care was initially funded and difficulty finding this type of Discharge To Assess beds. However, after contacting the NHS funding team, the Council confirmed a place at the Nursing Home could initially be funded through Discharge To Assess. I recognise Mrs B says she would have made a different decision had she had the correct information about what funding options were available. At the time, Mrs B told the Council the Nursing Home was one of the options she was willing to consider. As such, I cannot say that, even if the Discharge to Assess funding arrangements had been clarified sooner, Mrs C would not have gone to this Nursing Home. The Council acknowledged this had been a distressing time for Mrs B and appropriately apologised to Mrs B for any confusion.

Care provided at the Nursing Home: identifying and treating a UTI

24. Mrs B complained the Nursing Home provided poor care, specifically that it failed to take a urine sample to check for a UTI, even though the hospital had asked it to do so. Mrs B asked how Mrs C’s health could have worsened to such an extent during this period. She said she had not received an explanation for what happened during the period when a urine sample was supposed to be taken.
25. The care records for the 17, 18 and 20 February say that staff were unable to take a urine sample on those dates.
26. On 21 February, Mrs C’s COVID‑19 test came back with a positive result. Therefore, Mrs C was moved into isolation.
27. After 20 February, there is no further reference in the records to an attempt to take a urine sample until 27 February, when Mrs B raised the issue with the Nursing Home. On 28 February, a sample was taken. The Nursing Home said that as this was out of hours, it sought GP advice the next day, and arranged for Mrs C to go to hospital for treatment.
28. As noted above, in its response to Mrs B’s complaint, the Nursing Home accepted there was a delay in taking a urine sample. However, Mrs B said she still had not received an explanation for the delay, and why Mrs C deteriorated during this period.
29. The complaint response from the Nursing Home sets out the details from the records for 17 to 20 February. It states: “nothing further is then documented until 27th”. Although there is no reference to attempts to take a urine sample, there are care record entries for this period. These show the Nursing Home took Mrs C’s physiological observations regularly during this period, including after she was moved into isolation. These observations included temperature, blood pressure, respirations, pulse and oxygen saturation levels. The records also indicate the Nursing Home encouraged Mrs C with fluids every 30 to 60 minutes, and recorded her fluid intake.
30. The NHS England Patient Safety Strategy recommends that in nursing homes, a set of observations is taken within the first 12 to 24 hours of admission. This is then used as a baseline for future issues that arise. In people who may be susceptible to infection, the NICE Clinical Guideline 103 recommends that daily observations are carried out. Therefore, the records indicate the Nursing Home complied with these recommendations in carrying out daily observations for Mrs C, including when she was nursed in isolation due to COVID-19.
31. On 22 February, the records show Mrs C was “assisted with toileting”, but there is no reference to an attempt to take a urine sample. On 27 February, Mrs B contacted the Nursing Home to ask about a urine test. The records show she queried whether Mrs C had a urine infection. The Nursing Home took a sample the next day and Mrs C was admitted to hospital on 1 March.
32. The Nursing Home said that following Mrs B’s complaint, it had taken steps to prevent recurrence. It said it had improved communication from shift to shift, by including input from the deputy manager during staff handovers. The Nursing Home said it also held daily staff meetings, and used the nurse’s diary to record outstanding tasks.
33. These measures the Nursing Home has put into place will help reduce the risk of any similar occurrence happening again. However, there are further actions I consider the Nursing Home should take. Regarding the daily staff meeting, the Nursing Home should ensure that a representative from every area of the home is present. If a staff member cannot attend, there should be a handover record sheet to use at the daily meeting, to provide written evidence of the concerns raised for future reference. The Nursing Home explained it now uses a handover sheet during the daily meetings.
34. The Registered Nurses have a responsibility under the Nursing and Midwifery Council (NMC) to ensure that they keep those they are supervising informed and up to date on patient care. The NMC Code says Registered Nurses should “check people’s understanding from time to time to keep misunderstanding or mistakes to a minimum” (Section 7.4). In Section 8, Working Cooperatively, the NMC Code says Registered Nurses should maintain effective communication with colleagues. They should keep colleagues informed when sharing the care of individuals with other health and care professionals and staff, and work with colleagues to preserve the safety of those receiving care. They should also share information to identify and reduce risk.
35. With the oversight and supervision of the Registered Nurses, this guidance is equally applicable to all carers. Mrs C’s care records indicate the Nursing Home used agency staff. The Nursing Home should also make agency staff aware of the new handover procedures and meetings, and of the use of the nurse’s diary to record outstanding tasks for residents.
36. In view of the concerns raised by Mrs B, the Nursing Home should provide refresher training for staff on signs and symptoms of urinary tract infections and dehydration.
37. Regarding record-keeping, the NMC Code Section 10 says that records should be completed “at the time or as soon as possible after the event… identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need.” The guidance in section 10 is equally important to all that are employed as carers whether they are registered or not.
38. Based on the lack of information in the records about why a urine sample was not taken, I have not been able to add any further explanation for Mrs B about why this did not happen. There was fault with the Nursing Home in terms of its record-keeping about obtaining a urine sample. The lack of detail in the records about this means Mrs B has been left with uncertainty over whether a UTI could have been identified earlier, and whether this may have contributed to a deterioration in Mrs C’s health. As noted above, in its response to the complaint, the Nursing Home acknowledged that a sample was not taken, it apologised to Mrs B and waived the fees.
39. However, given the lack of information in the records on this point, the Nursing Home should provide further staff training on record‑keeping. In particular, this should include training on what detail to include in the notes that are entered, to help prevent recurrence.

Council safeguarding investigation

40. Mrs B complained the Council did not investigate properly when responding to the safeguarding referral. She complained the provider enquiry report, which the Nursing Home sent to the Council, was inaccurate and had information missing as it did not seek views from the person at risk or their representative. Mrs B also said the Council delayed in providing her with a response about the safeguarding enquiry.
41. In March 2022, following Mrs C’s admission to hospital, the Hospital Trust made a safeguarding referral to the Council. The Hospital Trust provided the following details: Mrs C had two falls in the Nursing Home, the family was concerned about care; and there were concerns about physiotherapy and the use of a Zimmer frame. On 6 March, Mrs B emailed the Nursing Home and the Council about delays in obtaining a urine sample, UTI, dehydration, low kidney function, Mrs C being found to have a fractured pelvis in hospital, and missing personal items. On 11 March, Mrs B sent a further email to the Council. She said she wanted to raise a formal complaint about dehydration, untreated UTI, Mrs C having a fractured pelvis, and weight loss.
42. The Council’s adult social care team wrote to Mrs B to acknowledge her email of 6 March. It said it would handle this as a formal complaint. The Council’s complaints team then spoke to Mrs B about her complaint. It also sent her an email to confirm it would respond formally to her complaint and that this would involve input from the Nursing Home.
43. The Council also opened a safeguarding enquiry under Section 42 of the Care Act (as set out in paragraph 15, above). It asked the Nursing Home to complete a provider enquiry report.
44. In April 2022, the Council adult social care team sent Mrs B a further email to “feed back outcome of safeguarding investigation”. This set out the Council’s actions in response to the safeguarding concerns:

• its contract team was working with the Nursing Home to improve the standard of care;
• it had made a referral to the CQC;
• the Council contract team would make an unannounced visit, “to ensure improved quality of care”;
• its safeguarding and risk manager was working with the Nursing Home to improve the standard of care.

45. The email also said the Council was working with the Nursing Home to provide a response to Mrs B’s formal complaint, and the adult social care case would be closed.
46. The Council and Mrs B then exchanged emails about progress on her complaint. Mrs B also asked what was happening with the safeguarding enquiry. She asked what action the CQC had taken over the Nursing Home.
47. In May 2022, the Council updated Mrs B, saying the Nursing Home was investigating her complaint and would share its response with her. The Council also said it would ask its safeguarding team to provide Mrs B with an update on the safeguarding enquiry and outcome. However, it is not clear whether the safeguarding team did then update Mrs B. The Council also suggested Mrs B contact CQC directly to find out whether it had taken any action.
48. In June 2022, the Nursing Home responded directly to Mrs B’s complaint. It said: “I would like to bring to your attention that this has already been dealt with via Safeguarding team as the same complaints had already been raised by yourself.”
49. Later that month the Council wrote to Mrs B, responding to her complaint about the advice given about care homes when Mrs C was in hospital. The response did not refer to the safeguarding issues raised, or to care and treatment at the Nursing Home.
50. Mrs B complained to the Council again and in August 2022, received a further response. The Council said Mrs B had raised her concerns as a complaint, and that it had also recorded a safeguarding referral. The Council said it had emailed Mrs B with the outcome of the safeguarding and actions taken in April. However, this email had not included a copy of the provider enquiry report.
51. Mrs B followed this up again. She said the Nursing Home had not responded to the part of her complaint about how Mrs C’s health had deteriorated before she went into to hospital, because this was to be covered by safeguarding. She said she had not had an explanation about this, and she had expected to receive a further response from the Council about it.
52. In September 2022, the Council responded. It said when Mrs B had first complained, it had advised her it would handle her email of 6 March under safeguarding; and that her email of 11 March would be investigated by the Nursing Home and the hospital social work team. In September, the Council also sent Mrs B a copy of the provider enquiry report that the Nursing Home had completed for the safeguarding enquiry in March. Mrs B said she had not seen this report before, and it contained gaps and mistakes. She said if she had seen the report earlier, she would have raised concerns about it then.
53. I have considered how the Council dealt with the safeguarding enquiry and how it communicated with Mrs B about this.
54. The Council’s email to Mrs B in April clarified that it was feeding back on the safeguarding enquiry. This was in line with the Council’s safeguarding policy. This says the person at risk, or their representative, should be made “aware of decisions reached in relation to the concerns… the person raising a concern should be in a position to know whether the concerns are being responded to”.
55. The Council dealt with the safeguarding concerns first, and then the remaining issues under the complaints process. The Council’s safeguarding policy states: “Where concerns cannot be resolved and the person at risk (and/or their representative) on their behalf, is dissatisfied with the response within this policy and procedures they may sometimes wish to make a formal complaint.” Therefore, the Council handled this in line with its policy to deal with the safeguarding matters first, and with any remaining issues as a formal complaint.
56. However, as set out in paragraph 41, above, Mrs B’s initial emails to the Council and Nursing Home each raised similar issues. This meant there was an overlap in the matters the Council said it considered under safeguarding, and those it considered as a complaint. Mrs B also received differing information about which of her emails would be considered under which process.
57. The Council could have given Mrs B a clearer explanation at the outset which specific issues would be handled under each process, as this is likely to have clarified this for her. The LGSCO guidance on effective complaint handling says setting out an understanding of the complaint, helps reduce the likelihood of a later complaint that concerns have not been addressed. I also recognise that had Mrs B received a copy of the provider enquiry report earlier, this is likely to have given her an opportunity to raise any concerns about it then.
58. While the Nursing Home responded directly to Mrs B regarding her complaint about the care provided, it said some of this had already been covered through the safeguarding process. Together with the Council’s communication with Mrs B about safeguarding, and the overlap between the issues being considered, this is likely to have caused uncertainty to Mrs B about how her concerns were being handled and whether she could expect further information about safeguarding.
59. Regarding the safeguarding enquiry itself, Mrs B complained the provider enquiry report had information missing, as the section on asking the views and wishes of the person at risk or their representative was left blank. However, on the Council’s safeguarding form, it has completed the section “Views of the person at risk”. It says the Council had previously assessed that Mrs C was not able to decide about discharge options or her care and support needs. The Council said therefore Mrs C might not be able to express her views or engage in a discussion about safeguarding concerns.
60. The safeguarding form also recorded the family had shared their concerns by email, and included the details of these concerns. Therefore, although the section of the provider enquiry report was blank, the Council’s records indicate it did consider the views of Mrs C’s family as part of its safeguarding enquiry.
61. The Council responded to the safeguarding referral appropriately and shared the initial outcome with Mrs B in a timely way. However, the Council was not clear with Mrs B about how it would handle her concerns between the complaints and safeguarding processes. It took too long to send her a copy of the provider enquiry report, even though Mrs B had asked for further information about the safeguarding enquiry. This was fault by the Council, causing uncertainty to Mrs B.

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Summary

62. The Nursing Home has previously upheld parts of Mrs B’s complaint and apologised to Mrs C and her family and waived the fees. During my investigation I also found fault by the Nursing Home in its record-keeping, causing uncertainty to Mrs B. The Nursing Home has also taken some steps to improve services. However, there are further actions the Nursing Home has agreed to take to improve services.
63. There was fault by the Council in the way it communicated with Mrs B about how it would deal with her concerns, and a delay in sharing the provider enquiry report. This caused uncertainty to Mrs B and meant she missed an opportunity to raise her concerns at the time. The Council has agreed to take action to remedy the injustice caused.

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Agreed Actions

64. Within one month of the final decision on this complaint, the Council will:

• Apologise to Mrs B for uncertainty caused by communication about how her concerns would be dealt with, and delay in sending her the provider enquiry report; and
• Pay Mrs B £150 in recognition of the uncertainty caused by the fault.

65. Within three months of the final decision on this complaint, the Nursing Home will:
• Ensure that new working practices and processes introduced following Mrs B’s complaint, including handover meetings, also include agency staff;
• Arrange further training for staff regarding record-keeping; particularly around what detail to include in the notes that are entered; and
• Arrange refresher training for staff on signs and symptoms of urinary tract infections (UTIs) and dehydration.

66. The organisations should provide us with evidence they have complied with the above actions.

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Final decision

67. For the reasons set out above, we uphold Mrs B’s complaint about the Council in its communication with her about how it would deal with her concerns, and a delay in sharing the provider enquiry report. We uphold Mrs B’s complaint about the Nursing Home in terms of its record keeping. I am satisfied the Council and Nursing Home have agreed to provide reasonable remedies for the injustice caused. I have completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman