Summary: Mrs E has complained about a nursing home in relation to the care of her husband, Mr E. I found fault with the Home in managing Mr E’s nutrition and personal hygiene and the Home has now carried out service improvements to address these faults. I did not find fault with the other issues in this complaint.

The complaint

1. Mrs E has complained about the care of her husband, Mr E, at a nursing home (the Home) between June and August 2021. Care UK owned and operated the Home. The care was funded by the NHS. The Council was due to take over funding for Mr E’s care in August 2021 but he died before this took place.
2. Specifically, Mrs E has complained about:

• a lack of nutrition leading to her husband losing weight,
• her husband’s buzzer being regularly left out of his reach,
• the way his continence needs were met,
• staff not regularly washing and dressing him in the morning,
• staff not regularly helping her husband to move between his bed and his chair and back,
• her husband being left to lie prone in bed and this could have brought on the pneumonia he suffered,
• her husband falling three times but the Home did not class them as falls or inform her of them,
• her husband being left socially isolated in the Home,
• staff not sending her husband to hospital earlier on the day he fell ill; and
• on the day he was admitted to hospital Mrs E rang the Home over 20 times and no one answered.

3. Mrs E has lost her husband who she said was expected to recover and return home.
4. Due to this she now needs carer support as he was her main carer, and this has affected her dignity.
5. Mrs E wants:

• the Team Leader at the Home to retrain,
• staff on the Home’s nursing unit to retrain,
• Care UK to listen to patients and families; and
• to prevent others suffering neglect, disrespect, isolation or losing their dignity.

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The Ombudsmen’s role and powers

6. 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).
7. 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.
8. 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

9. During my investigation I have considered evidence from Mrs E, the Council and Care UK. I have also considered the relevant guidance and legislation.
10. I shared my draft decision with the organisations and Mrs E for their comments. I considered these comments before making my final decision.

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What I found

Background

11. Mr E was discharged from hospital to the Home in June 2021 for six weeks to have his needs assessed under the Discharge to Assess scheme. This was a scheme which allowed for hospital patients to go into a care or nursing home to have their needs assessed before they either went home or to a care or nursing home.
12. In August 2021 Mr E contracted pneumonia and was admitted to hospital where he died shortly afterwards.
13. Mrs E raised several complaints with Care UK and received responses before approaching the Ombudsmen.

Lack of nutrition

14. Mrs E said the Home did not properly manage her husband’s food or fluid intake during his stay. She said her husband was six foot two inches but only weighed 51 kilos when he died.
15. Mrs E said staff did not spend enough time encouraging her husband to eat or drink.
16. The Home admitted that Mr E lost weight during his previous hospital stay and continued to lose weight at the Home. The Home said he lost nearly 3 kilos during his stay and agreed he weighed 51 kilos at the end of July 2021.
17. The Home went on to say it assessed Mr E as able to eat and drink independently and choose his meals from the menu. On occasions he only ate small amounts, but a dietician prescribed nutrition shakes to supplement his intake.
18. The Home said mealtimes were busy and staff could not sit with him to encourage him to eat as it was not one of his needs.
19. It went on to say it told a visiting nurse from Mr E’s GP about the continuing weight loss.

Analysis

20. Mr E had a body mass index of 15.7 which is below the healthy level of 18.5.
21. His care plan stated he could eat and drink independently but that he was high risk and had lost weight. It stated staff should monitor his foods and fluids and a dietician recommended a nutrition shake twice a day.
22. The guidance for a high risk Malnutrition Universal Screening Tool is to involve a dietician, set goals and improve and increase nutritional intake.
23. The care plan is in line with the guidance for someone with Mr E’s nutritional needs.
24. The daily food and fluid charts show that at first Mr E’s fluid intake was acceptable and roughly one and a half litres a day. However, he was sometimes only eating a quarter of his meal and turning down some meals.
25. The Home started the nutrition shakes after about a week and on most days staff offered these twice in a day. However, there is not enough evidence in the records that this happened every day.
26. In someone who was this high risk nutritionally, it was fault that staff did not record every time they offered Mr E nutrition shakes, even if he declined them.
27. Also, as the Home has said it did not have time to encourage Mr E to eat and drink more, it should have been accurately recording each instance it offered him shakes and food whether he declined it or not.
28. I have found fault in the nutrition of the Home either not offering or not recording when it offered Mr E food and shakes.
29. We cannot say this led to his weight loss, as he declined several of his meals, and sometimes ate little of them. He was also independent in eating and drinking. But the fault has led to uncertainty for Mrs E on whether the Home could have done more to address her husband’s weight loss.

Buzzer left out of reach

30. Mrs E said that she and Mr E’s social worker had noticed staff left his call bell out of reach several times. The social worker found a member of staff and told them the call bell was out of reach. However, the next day it was again out of reach.
31. Mrs E said this meant her husband could not call to staff and was isolated in his room.
32. The Home said at time Mr E did use the call bell, so it was unclear why it was sometimes out of reach. It reminded staff that call bells should always be within reach and any staff found leaving them out of reach deliberately would face disciplinary action.

Analysis

33. We have not been able to find in the records evidence of the call bell being regularly out of reach. However, the Home has taken right steps to prevent this happening to other residents.

Continence

34. Mrs E complained staff left her husband in a continence pad just for the convenience as he could use a urine bottle. This affected his dignity.
35. The Home said staff offered Mr E a bed pan or commode which he sometimes used. It did however use a continence pad as he could not always indicate when he needed the toilet. In addition, the Home said it offered Mr E a urine bottle but he could not use it.

Analysis

36. Mr E’s care plan when he first entered the Home stated he was fully continent and able to use the toilet with the help of one or two carers. It said he would only wake in the night for continence needs.
37. The care plan changed over his stay to say Mr E needed help with his continence needs and transporting to the bathroom when he asked. However, he was sometimes incontinent and had continence pads.
38. There is evidence Mr E’s needs changed during his stay at the Home which required continence pads to keep him dry. Staff also helped him on to the commode when he asked.
39. There was an instance in the records that he could use the urine bottle with help. There is not enough evidence for me to decide why Mr E did not use the urine bottle at other times and if it was available. However, I have not found fault with these actions by the Home as it documented when Mr E’s needs changed and acted accordingly.

Washing and dressing

40. Mrs E said her husband only had two showers during his whole stay at the Home. Also, he was often in only pyjama bottoms in the mornings.
41. The Home said according to its records Mr E had four showers during his stay, but he was given a fully body wash every day. It also said it made the effort to have Mr E dressed by 11am every morning.

Analysis

42. There is evidence in the records that Mr E was showered or washed at regular times. However there is insufficient evidence in the Home’s records that Mr E was given a daily body wash. This is a fault in either recording or in practice which leaves Mrs E with uncertainty her husband’s personal hygiene was maintained throughout his stay. I have not found evidence in the records that Mr E was not dressed regularly by 11am every morning so have not found fault with the Home in relation to the dressing issue.

Staff not regularly helping her husband to move between his bed and his chair and back

43. Mrs E said her husband should have been helped into his chair regularly for short periods and then helped back into bed for his own benefit. Instead, he was left in the chair in pain for up to an hour. This left him in agony as he was very thin and could not sit in a chair for long without it becoming uncomfortable.
44. The Home said staff confirmed that he found the chair uncomfortable. It also noted Mrs E asked for her husband to be washed dressed and sat in the chair by 11am each day.
45. The Home mentioned an occasion when Mr E only managed 20 minutes and then needed to go back to bed.
46. The Home said staff did try and encourage him to stay in chair to help prevent pressure sores. Pressure ulcers (pressure sores or bed sores) are areas of damage to skin and the tissue underneath caused by staying in the same position for lengthy periods.
47. However, the Home said if Mr E was uncomfortable staff would put him back in bed, some days he spent most of the day in bed at his own request.
48. The Home said it was not sure of the exact occasion when Mr E had to wait for an hour to return to bed. However, it said it had no reason to disbelieve Mrs E and so apologised for distress this caused her and Mr E.

Analysis

49. From the evidence in the notes Mr E seemed to prefer to be in bed a lot of the time. He could reposition himself which can help with pressure sore prevention.
50. There are instances when he was moved to his chair but wanted to back to bed. In view of this, and the fact the Home has apologised for the distress caused in this aspect of the complaint, I will not be recommending any further action by the Home as I have not found sufficient evidence of fault and it has responded appropriately to the complaint.

Mr E being left to lie prone in bed

51. Mrs E said her husband had previously suffered from pneumonia and was at risk of developing it again. Because of this she said her husband should have been upright in bed when he was awake.
52. However, Mrs E said her husband was regularly just lying on his back in bed, prone. She felt this contributed to him contracting pneumonia again.
53. The Home said staff knew Mr E was supposed to be supported upright in bed with pillows and he was on nursing bed with controls to raise it. The Home said without specific dates it could not check which times Mr E was left lying down when he was supposed to be upright, but it reminded staff to follow bed positioning plans.

Analysis

54. Advice following pneumonia is to reposition a patient in bed every hour when awake and to stay upright.
55. There is nothing in Mr E’s care plan relating to his pneumonia care apart from that he had previously suffered from pneumonia and that he can reposition himself. There is some evidence in the records of him sitting upright at times, but this is not a regular entry that is checked daily for example.
56. Therefore, there is insufficient evidence that Mr E was left lying down or not encouraged to sit up and he could reposition himself and did sit upright at times.

Falls at the Home

57. Mrs E said her husband fell on one occasion as he had to try and get into his chair unaided. In addition, there were other occasions when her husband fell out of bed but the Home did not class it as a fall and did not inform her at the time.
58. The Home said staff denied Mr E ever fell.
59. However, the Home said he rolled out of bed twice onto a crash mat. Staff checked Mr E and he had with no injuries, so they helped him back into bed.
60. The Home have said the risk management policy in Care UK is that it uses bed rails as a last resort. In Mr E’s case, he had confusion which would have meant that bed rails were not suitable due to risk of injury and entrapment.
61. The Home went on to say the risk management strategy in this case is that it uses low rise beds which are only several inches from the floor. It uses these with crash mats next to the bed should a resident roll from bed.
62. If it knows a resident to roll from bed due to restlessness and has a care plan in place, then staff would log this in their daily record, but not as an incident.
63. Further, the Home confirmed it would log as a fall a ‘fall from height’ such as if the bed was in high position.

Analysis

64. The Home is correct in that no falls in the notes but that there are a couple of occasions when Mr E rolled out of bed. If this was only from a few inches of height and onto a crash mat, with no injuries recorded, this does not amount to a fault by the Home.
65. The Home also communicated with Mrs E about the rolling out of bed on at least one occasion and so the response it has given her is reasonable.

Social isolation

66. Mrs E said her husband in his room on his own all day and staff only took him out once during his stay. This led to him feeling isolated as he had no one to talk to.
67. The Home said when Mr E first became a resident, he had an isolation plan in place due to infection control. However, his door open and staff checked on him every hour.
68. The Home went on to say this was a nursing unit and the needs of the residents meant most were cared for in their rooms.
69. Also, due to the COVID-19 pandemic, care facilities were working differently with movement around homes not encouraged to try and minimise infection spreading.
70. The Home agreed the only occasion in the six weeks Mr E went outside was for a barbecue. But he did prefer to be in bed and was uncomfortable being out of his bed for any length of time.

Analysis

71. I could not find anything in the Care UK Pandemic Event Plan about isolating residents in their rooms, apart from if there was an outbreak at the Home, which there was not.
72. However, it was in Mr E’s care plan that he had reduced mobility due to pain related to his being in a wheelchair. It also stated Mrs E would visit as often as possible and keep in contact through his mobile phone.
73. Due to Mr E’s pain when being sat out in a chair or wheelchair, it is understandable that he could not attend more social events. Also, he was having welfare checks every hour so had regular contact with staff, if not other residents. Further, the fact the other residents were also usually in their own rooms means there would not have been much opportunity for social interaction.
74. Taking this into account I have not found enough evidence of fault in how the Home managed Mr E’s social interaction.

Delay in the Home calling an ambulance and not answering Mrs E’s calls

75. Mrs E said she spoke to her husband earlier in the day he went to hospital and he did not sound good. She said she then rang the Home throughout the day over 20 times to pass on her concerns but no one answered.
76. Mrs E said the Home called her at 745pm that evening to say Mr E had gone to hospital with a chest infection.
77. Mrs E believes her husband was ill when she spoke to him that morning but staff did not notice until they brought him his evening meal. This meant a long delay in getting her husband hospital treatment.
78. Mrs E in also unhappy the Home did not respond to her calls during which she could have told them her husband was ill and needed attention. Mrs E pointed out that her husband died of pneumonia in hospital the next day and this could have been prevented.
79. The Home said on the day, Mr E had a shower, his breakfast and lunch and there were no concerns as he spent the day in bed watching television.
80. Staff gave him his afternoon tea and dinner but he was not hungry. However, when staff went to change him that evening they noticed he was out of breath so a nurse took his observations. Mr E’s oxygen level was low, so the Home called an ambulance.
81. The Home said staff took Mr E’s temperature daily and it was always normal. In addition, staff were performing hourly welfare checks and there was no indication such as chest pain or difficulty breathing, that Mr E was unwell until that evening.
82. The Home said that staff would not miss that number of calls as residents’ families, pharmacies and doctors would call the Home. So staff had to answer calls regularly. The only time staff may not have answered the phone was when staff were attending to Mr E before phoning an ambulance and then the nurse rang Mrs E straight away to inform her.

Analysis

83. The records state that Mr E was settled on the day he went to hospital and staff were carrying out welfare checks. In addition, his temperature which was taken at the time just before he went to hospital was within normal range.
84. I have not found sufficient evidence of calls going unanswered at the Home. However, even if Mrs E had got through to pass on her concerns, there is no guarantee that his observations would have been out of a normal range and so staff would have called an ambulance. Taking this into account I have not found fault with the Home in relation to the events of this day as its response is backed up by the evidence in the records.

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Recommendations

85. Although I have not found fault in some of the aspects of this complaint, I have found fault leading to uncertainty for Mrs E in relation to nutrition and hygiene.
86. I would normally recommend that the Home apologise to Mrs E for the uncertainty caused by these faults. However, she has asked that it does not send an apology as she does not feel it would be sincere, or genuine and so she would not accept it.
87. I also proposed in my draft decision that the Home remind all staff of the importance of recording when nutrition is taken or refused and when residents are washed or have a shower.
88. The Home has provided us with evidence it has now told colleagues of the importance of recording all food intake and personal care.
89. For the reasons above I am not making any recommendations in this case.

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Final decision

90. I found with the Home in relation to nutrition and personal hygiene, but not the other aspects of this complaint.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman