Summary: We found staff from the Nursing Home failed to take Mrs U to the toilet when she asked. The Nursing Home also did not keep full and accurate records. By not taking Mrs U to the toilet when she asked staff were not adhering to her care plan and this affected her human right to be treated with dignity. Poor record keeping hindered our investigation and means we cannot provide Mrs U’s daughter, Ms M, with a clear answer to her complaint. We also found the Council did not update its access system and sent a male carer which was not in Mrs U’s care plan. We are satisfied with the steps it took to remedy the injustice to Ms M. We recommend the Nursing Home apologise, make service improvements and a time and trouble payment to Ms M to address the faults we identified.

The complaint

1. Ms M complains about the care her mother, Mrs U, received from Ardenlea Grove Nursing Home (the nursing home), University Hospitals NHS Foundation Trust (the Trust) and Solihull Metropolitan Council (the Council) between January and April 2020. Specifically, she complains:
• The Nursing Home did not have enough staff to provide her mother with proper care
• Staff told her mother to soil herself even though she was not incontinent as there was not enough staff to take her to the toilet
• Nursing Home staff failed to clean and dress her mother’s wound properly
• During discharge planning, the Trust and the Council did not consider her needs in full and failed to put a suitable care package in place.
2. After her mother’s discharge home on 19 March 2020, Ms M complains:
• Although the Council was providing a care package of reablement care, one carer did not attend, and her mother fell
• On one occasion a male carer attended, this was not in the care plan and was not suitable.
3. Ms M complains that, because the Nursing Home did not clean the wound, Mrs U got an infection and needed hospital treatment. Ms M also says her mother fell when carers failed to attend her and cut her arm, which needed stitches. Ms M states she is shocked and depressed by how they handled her mother’s care. She feels her mother was denied human dignity while in the Nursing Home and this had a severe effect on Mrs U’s mental well-being.
4. Ms M would like the Nursing Home and care agency to improve their standards of care to prevent similar problems occurring for others. She would also like financial recompense in recognition of the distress she suffered because of the poor care provided to her mother.

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The Ombudsmen’s role and powers

5. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015 a single team has considered these complaints acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
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. The Ombudsmen cannot question whether a decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the organisation reached the decision. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
9. 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)
10. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.

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How I considered this complaint

11. I considered the complaint Ms M made to the Ombudsmen and information she provided on the telephone and by email. I also considered the information the Council, the Trust and Nursing Home provided in response to my enquiries. I also got advice from a Nurse with relevant experience.
12. I shared a confidential draft with Ms M, the Council, the Trust and the Nursing Home to explain my provisional findings and invited their comments. I considered their comments before making a final decision.

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What I found

Background

13. Mrs U was 96 years old during the incidents under investigation. She had a brain tumour, lung cancer, and COPD. She went in to Ardenlea Grove Nursing Home from hospital on 31 January 2020. She stayed there until 19 March, when she went back to her own home with a reablement care package.

Analysis

The Nursing Home did not have enough staff to care for Mrs U

14. Ms M complains the Nursing Home did not have enough staff to look after her mother. She says carers told Mrs U to soil herself, even though she was not incontinent. Ms M says there was not enough staff to take her to the toilet.
15. Mrs U had a care plan from 23 January 2020 which was prepared by the Nursing Home. It contained a continence assessment which said she “needs assistance to the toilet.” It added she could not control urine but was not faecal incontinent. A note said, “is able to verbalise, use bell if she needs the toilet”. It also stated she wore a pad for urine or loose stool. The daily notes reflect the same information. A note on 5 February stated “nil continence issues reported.” The evidence shows there was no reason for staff to think Mrs U was faecal incontinent and should use the pad instead of helping her to the toilet.
16. The daily notes record incidents when Mrs U asked for help to the toilet, but carers did not respond quickly.
17. On 5 February, Mrs U’s granddaughter was visiting her and spoke to a nurse as Mrs U was desperate for the toilet, but no one was answering her bell. The carers told her granddaughter they were helping another resident and would come soon so her granddaughter helped her to the toilet. The carers arrived as she was finishing.
18. On 13 February, Mrs U pressed the call bell, but no one came to help her, she went to the toilet in her pad. Mrs U’s son, Mr P, spoke to staff about this and the notes say the Nursing Home took statements. I asked the Nursing Home for copies of these statements, but it could not find them, so I do not know what happened.
19. On 26 February, an Occupational Therapist (OT) visited Mrs U who found her to be unhappy. She told them she had asked to use the toilet at 6am and was left dirty in her chair. She said she had to dress herself without help. Mrs U said she didn’t like to wait when she asked for help.
20. On 28 February, Mrs U saw the same OT. Mrs U said the night before no one had been in to see her and she had had to do her bedtime routine on her own. The OT asked the carers about this and they said they went to Mrs U twice, but Mrs U was insistent no one had helped her. She also said no carers came to check her in the morning and she had washed and dressed herself. The OT explained she should use the call button, but Mrs U repeated she was upset no one came to check her even if she did use it.
21. I asked the Nursing Home if there would be circumstances when staff would ask a resident to soil themselves if they were wearing a pad. It said this was not something staff would ask and if it happened, it would do an internal investigation. The Nursing Home manager confirmed there was no record of an investigation into such an allegation on file, but it could not explain why the statements referred to in paragraph 18 were not on file either.
22. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 17.2.c states organisations should “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.” The Nursing Home has failed to keep accurate records, this is fault. This has affected our ability to fully investigate and left doubt about what happened.
23. The Health and Social Care Act 2008, Regulation 2014 states “service users must be treated with dignity and respect”. Ms M said despite her mother’s advance age, she was always well presented and looked after her appearance. The combination of Mrs U’s care plan, conversations recorded in the daily records and evidence from Mrs U’s family gives enough evidence to show Mrs U could use the toilet, wanted to do so but needed support.
24. I found no evidence carers told Mrs U to soil herself. However, I found evidence staff were not available to take Mrs U to the toilet when she used the call bell. On the balance of probabilities, the Nursing Home did not provide the care it knew Mrs U needed. This is not in line with the Regulations and is fault.
25. Ms M explained Mrs U was very distressed when she went to the toilet in her pad because the carers did not help her to the toilet. This caused her so much distress that on other occasions she went to the toilet by herself and fell and cut herself. This is an injustice to Mrs U. In addition, the failure to properly support Mrs U with her toileting needs is also a failure to Mrs U’s human right to be treated with dignity.
26. Ms M witnessed this distress in her mother and spoke to Nursing Home staff about her concerns. Ms M explained she is shocked and depressed by the way carers treated her mother. This is an injustice to her.

Nursing Home staff did not clean and dress a wound Mrs U had, which became infected

27. Mrs M complains Nursing Home staff failed to clean and dress a wound on Mrs U’s left foot. This became infected, and she needed antibiotics.
28. Mrs U’s records included a body map completed on 4 February 2020, which show the wound to her left heel. There was a wound care plan from 5 February 2020. On 6 February, Mr P told staff he was worried about the wound. Staff assessed and photographed the wound, and they asked a GP to visit the next day. They also contacted the care support team, which had a district nurse, for advice. The GP attended on 7 February and said the wound was not infected.
29. The NMC Standards for Competence for Registered Nurses explains nurses should recognise “the limits of their competence and knowledge … seek advice from, or refer to, other professionals where necessary.” There is evidence in Mrs U’s records Nursing Home staff followed guidance by accepting they needed help and spoke to a GP, a Tissue Viability Nurse (TVN) and the District Nursing service for advice on how to manage Mrs U’s wound.
30. The next note is on 13 February; they assessed the wound and Mrs U saw a GP. The note does not say if there were any clinical signs of infection. The records suggest from 13 February, Mrs U’s wounds showed signs of decline and needed more care.
31. On 18 February a District Nurse attended and reviewed Mrs U’s wound. The notes say one nurse had not been following advice and documented a new plan. The District Nurse noted “To contact home manager regarding training on wound assessment and dressings.” There is no further mention of this in Mrs U’s notes. I do not know what, if any, further action the District Nurse took. I also do not know if this hindered healing as the records do not say.
32. On 20, 21, 23 and 25 February the notes record assessments taking place. On 25 February Mr P again told Nursing Home staff he was worried about the wound. Staff explained they dressed the wound that morning and as there was no signs of infection, it was not necessary to contact a GP. Further assessments are noted on 27 February and 1 March 2020.
33. On 2 March a note suggests there may be signs of infection present, however the handwritten records are hard to read. The Nursing and Midwifery Council (NMC) Standards for Competence for Registered Nurses states nurses must “maintain accurate, clear and complete records”. The poor handwriting in Mrs U’s records has made it difficult for us to consider what happened. This is not in line with guidance and is fault.
34. The advice on 2 March was to “liaise with GP and TVN if infection noted”.’ A GP attended on 3 March and started Mrs U on a course of antibiotics. They asked for a wound swab on 4 March, however it was not swabbed or sent to the laboratory for testing until 20 March. In its final complaint response letter of 3 June 2020, the Trust could not explain why there was this delay and apologised. This caused uncertainty to Ms M about the care Mrs U received and whether if the swab had been sent sooner, the care she received would have been different. This is fault.
35. A note from 11 March 2020 states the TVN visited and looked at the wound; “previously looked infected and finished antibiotics yesterday, now no signs of infection.”
36. The National Institute for Health and Care Excellence (NICE) Clinical Guidance 179, Pressure ulcers: prevention and management advise all patients are at risk of developing pressure ulcers and on being admitted to a care home, a risk assessment should be carried out. 1.1.3. states “consider using a validated scale to support clinical judgement (for example… the Waterlow scale) when assessing pressure ulcer risk.” Staff should update the Waterlow scale every seven days if there are no significant changes. Mrs U’s records show a completed Waterlow Scale assessment on 5 February and 15 March 2020.
37. 1.4.1 states staff should “document the surface area” and 1.4.3. states “categorise each pressure ulcer using a validated classification tool”. Mrs U’s records show staff only recorded the length of the ulcer in most recordings and did not complete the other information.
38. I have found evidence the record keeping by the Nursing Home staff was not an expected standard, and this is fault. I can understand why Ms M would have been distressed knowing her mother had a wound which was worsening, but I do not know and cannot assume the wound worsened because of inadequate care. Wounds can deteriorate very quickly even with good care.
39. While the records are inadequate, I have seen evidence the wound was dressed correctly except on 18 February when the District Nurse mentioned the nurse not following advice. However, it was an isolated entry and there is no further evidence to show this was an ongoing issue. Staff also sought advice from a GP, a TVN and the District Nurses when they needed it.

Discharge planning

40. Ms M complains during discharge planning, the professionals did not fully consider her mother’s needs and failed to put a suitable care package in place.
41. On 5 February, a note says Mrs U was keen to regain her previous independence and wanted to go home.
42. On 17 February, the Physiotherapist spoke to Mrs U about discharge planning. She again said she wanted to go home, and she was happy with any support they put in place for her. Mr P spoke to the Physiotherapist later that day and said he did not want discharge planning conversations with Mrs U without a member of the family present as it confused her. The Physiotherapist said there would be an assessment of Mrs U’s home and Mr P said he did not want this to take place without him or Ms M present.
43. On 18 February, Mrs U told the OT she wanted to go home and became tearful when talking about it.
44. A multi-disciplinary team (MDT) meeting on 19 February noted Mrs U wanted to go home. A note said there needed to be a family meeting to discuss discharge planning.
45. An MDT meeting on 20 February discussed the discharge plan for Mrs U. She wanted to go home and had capacity to decide. The notes state Mr P was not happy and believes she should not be on her own.
46. An OT assessed Mrs U’s home on 21 February with Ms M there. The OT discussed a reablement referral with Ms M after finishing the assessment. They were happy Mrs U had been progressing with therapy but had concerns about her foot drop and they were waiting for a foot up splint to arrive before therapy could carry on. They felt Mrs U was lacking in confidence and would benefit from reablement. The OT told Mrs U about the result of the assessment on 24 February, and they told Mr P about the next steps as he was not present.
47. A further MDT meeting on 26 February noted Mrs U wanted to go home and they should arrange a meeting with Mr P to discuss. The Trust confirm it would make a referral to the Council’s reablement service. Mr P called after the meeting to explain he was worried about the equipment delivery, the times of the carer visits and if she would be safe in the night. A further meeting was arranged for 5 March to discuss these concerns.
48. On 28 February, the OT spoke to Mrs U’s family and asked if they could order the equipment for her return home. Both Mr P and Ms M agreed. They ordered the equipment the same day.
49. An MDT meeting took place with the family on 5 March and on 6 March the Trust made a referral to the Council’s reablement team. The Trust had responsibility for coordinating Mrs U’s release from the bed at the Nursing Home. The referral to the Council sought four care visits a day.
50. The records show continued communication between Mr P, Ms M and the OT about equipment delivery and potential issues post discharge. Mrs U repeated on 10 March she wanted to go home, and they told her this was in planning.
51. When the Council received the referral, its Reablement Facilitator reviewed Mrs U’s social care records, spoke to the Trust and staff at the Nursing Home and Mr P and Ms M. A note from 17 March shows the Facilitator had concerns Mrs U’s condition would not enable her to take part in the reablement programme as she had high care needs. The Nursing Home and the Trust both showed her health was stable and reablement was suitable. The same note shows Mr P strongly felt they should allow her to go home as this was her wish, and she should be independent if she wanted. He was certain she would improve in her own home with support. The Facilitator was happy with these explanations and supported Mrs U returning home with the suitable equipment and support package in place.
52. The Social Care Institute for Excellence explains “reablement services help people to retain or regain their skills and confidence so they can learn to manage again.” It adds “reablement is an approach that, irrespective of diagnosis, aims to assist people to continue to live as they wish.” Mrs U said many times she wanted to return home and “get back to normal.” Mr P at first had concerns for her safety, but at the last MDT meeting, he said they should respect Mrs U’s wishes and allow her to choose to be independent.
53. The Care and Support Statutory Guidance 2.14 states “‘Intermediate care’ services are provided to people, usually older people, after they have left hospital or when they are at risk of being sent to hospital. Intermediate care is a programme of care provided for a limited period of time to assist a person to maintain or regain the ability to live independently – as such they provide a link between places such as hospitals and people’s homes, and between different areas of the health and care and support system – community services, hospitals, GPs and care and support”.
54. The Trust’s Discharge and Transfer of Care Policy v7.0 states “patients and carers must be involved at all stages of discharge planning”. It adds “discharge planning and assessment requires the use of a complete multi-professional approach to ensure all of the patient’s discharge criteria are met.”
55. Ms M believes the organisations did not put an effective care package in place for Mrs U and this resulted in her needing to go to hospital after a fall. The records show extensive communication between the Nursing Home, the Trust, the Council, the professionals who cared for Mrs U, Mr P and Ms M. I have seen evidence they respected Mrs U’s wishes to go home and they considered any concerns properly. I have seen evidence they addressed the issues identified in therapy suitably and everyone understood Mrs U’s dropped foot would continue to be a problem as it would not respond to therapy. I understand Ms M feels Mrs U did not cope well when she returned home and recognise there were incidents. However, I cannot say these incidents happened because of ineffective discharge planning. I find no fault here.

Events after discharge home on 19 March 2020

56. Ms M complains the reablement care provided to Mrs U between 19 and 22 March 2020 was not enough. On one occasion a male carer attended but Mrs U said in her care plan she did not want a male carer. On another occasion, the carer did not enter her property using the access instructions and she was alone.
57. Mrs U left Ardenlea Grove Nursing Home with a reablement care package of four visits a day on 19 March 2020. Her family and the professionals involved in her care agreed this care package before she left the Nursing Home. Her reablement plan confirms visits would take place at 07:00 – 07:45, 12:40 – 13:10, 16:00 – 16:30 and 19:00 - 19:30 each day.
58. When the carer arrived for the 16:00 visit on 20 March, the carer found Mrs U on the floor with a cut to her arm. The carer called Mr P who asked them not to call an ambulance but to wait for him to arrive. The carer did so, and Mrs U later went to hospital for stitches. The carer did not attend the evening visit as Mrs U was in hospital, but Mr P told the service Mrs U would need visits as scheduled.
59. Ms M complained Mrs U fell and cut her arm because a carer did not attend at the expected time. I have reviewed the available records and I have seen evidence the carers did attend at the times in her reablement plan.
60. On the morning of 21 March, a male carer attended for the 07:00 visit and could not access Mrs U’s flat. The carer spoke to his supervisor and went to his next call. On his return at 08:28, he stayed with Mrs U for an hour, but she refused any care as it was a man.
61. The case notes show a telephone call took place between the service and Mr P on 18 March. This call confirms Mrs U’s front door would be unlocked so carers could gain access. The service knew it could gain entry to the main building through the door entry. The note states “I will inform the carers.” The Council has explained their scheduling system allows the transfer of information to their carers’ mobiles. There is no evidence the Council told the carers the information provided by Mr P in the call on 18 March.
62. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 17.2.c states organisations should “maintain securely an accurate, complete and contemporaneous record in respect of each service user.” The Council did not record the correct access information to Mrs U’s property so the carer did not know the door was unlocked. This is fault as this information was available to the service, but not recorded in the relevant place.
63. The Council has agreed it should have passed on the access information it had to the attending carer.
64. When the carer returned later for the morning visit, Mrs U refused care because of the male carer. We do not know if they discussed the possibility of a male carer because Mrs U’s records do not say. As it did not record her wishes, we do not know if they discussed a male carer visiting. This is fault.
65. The National Institute for Clinical Excellence Guidance Intermediate care including reablement 1.3.3 states “during assessment identify the person’s abilities, needs and wishes so they can be referred for the most appropriate support.”
66. The Council has accepted a male carer should not have attended without discussion with Mrs U. This is fault.
67. A male carer visited Mrs U which caused her distress. This is an injustice to her. There is also an injustice to Ms M who found her mother upset about the incident, so much so she had cause to complain.
68. During its local investigation of Ms M’s complaint, the Council agreed there was fault. In its letter of 7 October 2021, the Council apologised to Ms M and offered a time and trouble payment of £300, which she accepted. The Council also said it would review its:
• Processes for communicating with referrers to ensure they are provided with the essential information they need to give good quality care and support
• Processes for ensuring communication regarding male carers potentially attending, and preferences around this takes place and is recorded and checked by supervisors
• Practices for ensuring effective communication between managers and those providing the care package to ensure important information such as access is passed on
69. As part of this investigation, I asked the Council for evidence it had completed the actions. It provided evidence of completion of the reviews indicated and explained the changes it had made to its processes.
70. In summary, the Council has recognised it should not have sent a male carer to Mrs U as it did not know if she wanted one. The Council also recognised it did not update its system with the flat access information and this meant the carer did not know the door was open. As Mrs U has now died, we cannot remedy the injustice to her. The Council apologised to Ms M and paid her £300. I consider this enough to address the failings and put right the identified injustice.

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Agreed Actions

71. As Mrs U has now died, we cannot remedy the injustice to her. Instead, we make recommendations to remedy the injustice to Ms M. The Ombudsmen recommended, and the organisations agreed the following actions.
72. Within one month of the date of the final decision the Nursing Home will write to Ms M to:
• Acknowledge their responsibility for the faults identified in paragraphs 14-39
• Apologise for the impact of the faults to Ms M for the avoidable frustration and distress caused
• pay Ms M £300 to recognise the impact seeing Mrs U in distress caused her, and for the lack of clarity an independent investigation has been unable to provide due to poor record keeping.
73. The Nursing Home will also provide evidence of completion of the recommended actions to the Ombudsman within the same time frame.
74. Within two months of the date of the final decision the Nursing Home will:
• Remind all staff of the importance of keeping accurate records in line with guidance referenced in paragraphs 22, 29 and 36 and provide evidence of this to the Ombudsman.

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Final decision

75. I partly uphold Ms M’s complaint. I found fault which led to an avoidable injustice to Ms M. The agreed actions will provide a suitable remedy.

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Investigator's decision on behalf of the Ombudsman