Summary: We found fault with the Care Home who did not keep accurate or up-to-date records. We also found fault with the Integrated Care Board who do not keep a register of patients receiving s117 aftercare in its area. We found no fault with the actions of the Council or the Trust. The identified faults caused avoidable distress and frustration to Mrs Q. We recommended an apology and service improvements to address the injustice.

The complaint

1. Mrs Q complains about the care and treatment her brother, Mr R, received at The Coach House Care Home (the Care Home). Specifically, she complains:
• Staff did not notice Mr R had a mini stroke on 10 December 2020 when she visited
• Staff did not follow his care plan, and only updated his notes months after his death
• Staff did not call 111 for advice, as directed by a doctor, when his condition worsened
• Staff did not give mouth care, and
• Staff did not notice Mr R was hyperglycaemic.
2. Mr R received S117 aftercare. Mrs Q complains Norfolk & Suffolk NHS Foundation Trust (the Trust) and NHS Norfolk & Waveney Integrated Care Board (the ICB) did not understand his needs. She questions the fitness of placing her brother where staff could not perform nursing duties. Mrs Q would like to know why they did not move him to a more suitable home when he showed rapid decline.
3. Mrs Q also complains about Norfolk County Council (the Council) who would not look at her complaint. It instead told her it had conducted a safeguarding enquiry.
4. Mrs Q has many unanswered questions about the care her brother received. She watched his rapid decline and despite doing all she could to help him, felt nobody was listening. This caused her frustration and distress at an already difficult time.
5. She also says the organisations caused her further distress in the local complaints process as they have not fully answered her, and this has left her with more questions.
6. Mrs Q would like an acknowledgement of the mistakes made in Mr R’s care, an apology and service improvements to ensure no other family goes through what they have.

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The Ombudsmen’s role and powers

7. 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)
8. 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)
9. 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.
10. 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))
11. 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

12. I considered the complaint Mrs Q made to the Ombudsmen and information she provided on the telephone and by email. I also considered the information the Council, the Trust, the ICB and the Care Home provided in response to my enquiries. I also made an enquiry to Mr R’s registered doctor to get more information to help this investigation.
13. I shared a confidential draft with Mrs Q, the Council, the Trust, the ICB and the Care Home which explained my provisional findings and invited their comments on them. I consider the comments I received before making a final decision.

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What I found

Background

14. The Mental Health Act 1983 (the MHA 1983) sets out when a person can by law be admitted, detained and treated in hospital against their wishes. Under the MHA 1983, when someone has a mental disorder and is putting their safety or someone else’s at risk they can be detained in hospital against their wishes. This is sometimes called ‘being sectioned’.
15. A person can be detained in hospital under section 2 of the Act for assessment and for treatment after the assessment. A person can be kept in hospital under section 2 for a maximum of 28 days. Before the person is discharged, a social care assessment should take place to see if they have any social care needs the council should meet. Section 3 is to provide treatment and detention can last for a maximum of six months. As with section 2, before discharge, a social care assessment should be done.
16. Mr R had vascular dementia. He was held under section 2 of the Mental Health Act 1983 in late 2018. His stay in hospital moved to section 3 detention due to some behaviour he showed. They released him in early 2019. He was held again under Section 3 later in 2019.
17. Due to his continuing difficult behaviour, Mr R had several different care placements jointly organised by the Council, the Trust and the ICB. He went to The Coach House Care Home, which is a specialist placement for those with dementia and other mental health issues, in May 2020.
18. Mr R’s health worsened from 10 December 2020. On 13 December, paramedics attended and staff at the Care Home discussed a Recommended Summary Plan for Emergency Care and Treatment (RESPECT) form. This “creates a personalised recommendation for clinical care in emergency situations where you are not able to make decisions.” As Mr R did not have capacity, the form was filled in with Mrs Q. She decided she did want him to go to hospital for treatment. The form was put in place on 18 December 2020.
19. The complaint Mrs Q made to the Ombudsmen is about events from 10 December until Mr R’s death in hospital later that month.

Mini stroke on 10 December 2020

20. On 10 December 2020, Mrs Q visited Mr R. Mr R was sat behind a screen due to the Care Home’s COVID-19 prevention measures. She explains at the beginning of the visit he was talkative, but suddenly he slumped to one side and lost the ability to speak. Mrs Q called staff as she could not approach him herself, and they took him to his room. Mrs Q says the staff told her he was tired. Mrs Q believes Mr R showed all the signs of a mini stroke and does not understand why staff weren’t concerned.
21. I reviewed Mr R’s daily care notes for 10 December. There is no mention of the events explained by Mrs Q, only that Mr R had cut his finger, and a nurse dressed it.
22. I asked the Care Home manager if they had any recollection of what happened, and what evidence they considered when responding to Mrs Q’s complaint. They explained the Care Home had received no confirmation from any medical professional Mr R had had a stroke on 10 December.
23. Mrs Q was upset at witnessing her brother slump to one side and then be unable to talk to her.
24. When investigating complaints, if there is a conflict of evidence, the Ombudsmen may be unable to make findings. I have considered the evidence available and due to the accounts being so different, I do not know if Mr R had a stroke on 10 December but there is no evidence in his records to suggest he did. Because of this, I do not know whether Care Home staff acted correctly.
25. I am reassured by information provided by the Care Home manager; they told me staff are trained to recognise signs of a stroke. Mrs Q’s complaint has reminded staff of what to look for and what to do. The Care Home has taken steps to ensure an incident of this kind does not happen, which is what we would expect as the result of a complaint.

Record keeping

26. Mrs Q asked the Care Home for a copy of Mr R’s care plan as she worried about the care he received. The Care Home told her this was not available because they had not written up the care plan. Mrs Q complains this should not have happened as care plans should always be in place to ensure best practice in care.
27. In its complaint response of 3 September 2021, the Care Home accepts the care plan created in September 2020 was not written when Mrs Q asked for it in December. It explains despite this, monthly reviews and risk assessments took place and were signed off by suitable staff.
28. Mr R’s records show the latest care plan in his file is from 7 September 2020 but it does not say when it was written. We know it was not available to Mrs Q when she asked on 10 December 2020.
29. The risk assessments show various entries, the last one on most of the documents is 19 October 2020. On some documents, an entry states “05/12/2020 – reviewed care plan, no changes”. This entry is initialled and the complaint response refers to it as the ‘keyworker update sheet’.
30. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. Regulation 17 states “records relating to the care and treatment of each person using the service must be kept and be fit for purpose. Fit for purpose means they must: be complete, legible, indelible, accurate and up to date, with no undue delays in adding and filing information, as far as is reasonable.”
31. Regulation 9 explains care planning should focus on the person and “plans should include an agreed review date”.
32. I do not know when the Care Home wrote Mr R’s care plan and the care plans provided by the Care Home do not include an agreed review date. The Care Home has not explained why there was the delay in writing the care plan up or provided any reassurance this practice is not continuing. While I can see reviews took place regularly, the last review being 5 December 2020, the delay in writing up the plans and not including a review date is fault.
33. The Care Home caused Mrs Q unnecessary distress when they told her Mr R’s care plan was not available for her to look at. This made her question the quality of the care Mr R received, especially after he started to show signs of his health worsening. During the local complaints process the Care Home did not provide any reassurance to Mrs Q about why it happened, and it would not happen to others. This is an injustice to her caused by the identified fault.

Staff did not call 111

34. Mrs Q complains despite advice from Mr R’s doctor, that if his condition worsened staff should call 111 for advice, they did not. Mrs Q believes Mr R should have gone to hospital sooner.
35. Mr R’s GP summary shows staff called 111 on 13 December as Mr R had fallen. On 16 December, staff called 111 again as Mr R had a fever and was vomiting. 111 contacted Mr R’s doctor, who visited him. The doctor decided to test his blood to rule out infection.
36. Staff called 111 on 17 December. 111 told staff to do two-hourly checks and call back if Mr R’s condition changed. Mr R’s observation charts show staff checked him at least every two hours and helped him when he needed it.
37. From 18 December, Mr R’s notes show the care workers were checking Mr R every two hours and his doctor was giving advice. On 22 December Mrs Q went to see her brother and was worried about how ill he looked. She called his doctor first and then called an ambulance for Mr R. He went into hospital later the same day.
38. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulation 12(2)(i) says “a care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents.” In practice this means when care staff notice a new or worsening health condition in a resident and they do not know what the best care to give, they should contact suitable professionals for advice.
39. Mrs Q believes Care Home staff could have helped Mr R sooner. She was so worried about his condition she called his doctor herself and then asked a care worker to call an ambulance. Mrs Q was distressed at seeing the condition her brother was in when she visited and felt she had no choice but to get advice herself on what to do.
40. I have seen evidence which shows care workers did follow the advice given to them by 111 to conduct two-hourly checks. I have also seen evidence Mr R’s doctor asked for blood tests and was in frequent contact with care workers about his condition. It was suitable for the doctor to manage Mr R’s continuing care needs as they knew Mr R better than 111, who could only provide general advice based on his presentation.
41. In summary, care workers did follow the advice given by 111, but Mr R’s health continued to become more unwell. I have not seen any evidence care workers did not follow the advice given to them by 111 or by Mr R’s doctor.

Mouth care

42. Mrs Q complains on 22 December the Care Home did not give Mr R mouth care. She explains he couldn’t speak, he wasn’t drinking, his lips were dry and cracked and the skin around his mouth turned white. Mrs Q spoke to a care worker and asked why they were not giving Mr R mouth care to make him more comfortable. The care worker told her they were not trained.
43. The Royal College of Nursing explains mouth care includes “cleaning the lips, tongue, roof of the mouth, gums, teeth and dentures.” The aim is to “keep the mouth moist, clean and comfortable.” They say it is an important part of end-of-life care, or when people become unwell and cannot look after their own mouths effectively.
44. I looked at Mr R’s care records. On 21 December staff note he would not open his mouth and he refused mouth care. On 22 December, the notes say he also refused mouth care.
45. The Care Home Manager told me the care workers who helped Mr R are trained to provide mouth care.
46. Mrs Q was very distressed at seeing Mr R’s mouth in bad condition and she knew he was unwell. She spoke to a care worker to prompt them to help Mr R be more comfortable.
47. The evidence shows care workers did try to give mouth care to Mr R but he refused. This contrasts with Mrs Q’s account. The lack of care given to Mr R left him in avoidable pain and discomfort, but the records show care workers did try to help him. It is understandable this would have caused distress to Mrs Q but I cannot see this is because of actions by the care workers.

Diabetes management

48. Mrs Q complains staff at the Care Home did not manage Mr R’s diabetes effectively. When he went to hospital, his blood sugars were high, and he was hyperglycaemic. This is when the level of sugar in the blood is too high and can make you feel unwell. Mrs Q complains Care Home staff should have checked his blood sugar when he became unwell and provided better care.
49. Mr R’s care plan and nursing needs assessment show he had type II diabetes which was managed through medication and diet. A note in Mr R’s care plan on 19 November 2020 says he “eats a normal diabetic diet”.
50. The Care Home did a diabetic assessment on 22 November 2020. It says Mr R should have a low sugar diet and “if he becomes unwell, the Head of Shift MUST be informed, who in turn will inform his Dr which they will provide the home with glucose check machine if needed too.” The same document details the signs of hyperglycaemia. The evidence shows Care Home staff knew Mr R was diabetic and staff should watch him for signs of hyperglycaemia.

Nutrition

51. I reviewed Mr R’s nutrition charts for the days before he became unwell; staff did not accurately log his intake. Most entries say “all main” or “all pudding” with no suggestion of amount or what food he ate. Mr R’s records show other causes of concern; on 17 September 2020 his care notes show staff gave him, and he ate, four pieces of cake. This is not in line with his care plan which says he should be on a low sugar diet.
52. I refer to Regulation 17 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, mentioned in paragraph 31. I do not know if Mr R had a low sugar diet as his nutritional intake was not accurately recorded. This is not in line with his care plan or guidance. This is fault.

Blood monitoring and medication

53. The National Institute of Clinical Excellence (NICE) provides guidance on blood monitoring in adults with type II diabetes. At 1.6.13 it says there is no need to routinely monitor blood glucose levels “unless
• the person is on insulin or
• there is evidence of hypoglycaemic episodes or
• the person is on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery”
54. I asked Mr R’s doctor what advice they gave to staff when Mr R went into the Care Home. They explained Mr R did not meet the NICE requirements for regular blood monitoring, so they did not ask the Care Home to do this. Mr R’s doctor prescribed gliclazide, a medication used to manage type II diabetes.
55. Mr R’s records contain digital medication sheets. After reviewing all documents for this investigation, I found the medication sheets given by the Council are different to those given by the Care Home. The sheet for December from the Council does not list gliclazide, the one given by the Care Home does.
56. The medication chart from the Care Home shows Mr R took gliclazide every day in December up to the morning of 19 December. On 20 December, Mr R’s care notes show he refused medication and was spitting it out. The records also show a discussion with Mr R’s doctor and they asked Care Home staff to stop the gliclazide if Mr R was not eating.
57. The Care Quality Commission (CQC) issued guidance in 2020 about the importance of keeping accurate digital records. Specifically, they said digital records need to be kept up to date to “help to minimise risks such as medication errors.” As the Care Home gave a different medication sheet to the one the Council did, I cannot know whether Mr R received the correct medication. Keeping two sets of medication sheets for the same resident for the same period is not in line with guidance. Staff would not be able to say with certainty which chart was correct, and this could lead to administration errors. This is fault.
58. Mr R’s GP summary shows his doctor did not know what his average blood sugar was, as there had been no readings since Mr R entered the Care Home. The doctor therefore could not say if his blood sugar was higher than usual.
59. On 18 December, Mr R’s blood sugar level was 22.2mmol/l. His notes show he was not eating or drinking. On 19 December, his blood sugar level was 22.6mmol/l. Care workers spoke to a diabetic nurse. The entry on Mr R’s GP summary says “denies hypos and does not appear to be symptomatic of raised BS. Advised to observe and give meds as prescribed only to give gliclazide when he eats as risks of hypos still there”.
60. The British Diabetic Association explains hyperglycaemia can happen when a person’s blood glucose or sugar level is too high. Anything above 7mmol/l before a meal, or 8.5mmol/l two hours after a meal is high. They also explain infection could cause hyperglycaemia.
61. Mrs Q believes Care Home staff should have noticed Mr R was showing signs of hyperglycaemia and regularly tested his blood sugar levels. When she visited Mr R she saw how unwell he was and thinks staff should have done more.
62. The Care Home did not regularly monitor Mr R’s blood sugar levels so I cannot know if Mr R was hyperglycaemic. His blood sugar levels were high, but he was not taking his medication at the time. His doctor did not know Mr R’s baseline reading so the scores may not have been high for him. I do not have enough information to make a finding but can appreciate why the events would have been distressing for Mrs Q and why she was concerned.

Summary

63. The evidence shows the Care Home knew Mr R was diabetic and were not required or instructed to monitor his blood sugar. I have also seen evidence Mr R’s doctor was managing his diabetes. When he became unwell, Care Home staff spoke with a diabetic nurse and followed the advice they gave.
64. Mr R was hyperglycaemic when paramedics attended, but as explained, this may have been because he was not taking his medication or because of an infection. The Council did a safeguarding enquiry after his death, which will be considered at paragraph 77.
65. I find fault with the recording of his nutritional intake which has meant I do not know if he was being given a low sugar diet as advised in his care plan. This caused an avoidable distress to Mrs Q as she was worried Mr R was not looked after suitably.

Section 117 (s117) aftercare

66. Mrs Q complains the Trust and the ICB did not understand Mr R’s needs. She questions the fitness of placing her brother where staff could not perform nursing duties.
67. Mr R was in another residential Care Home, Care Home X, before August 2019. He became unwell and had a stroke and needed to go into hospital. After this, Care Home X felt it could no longer care for him and asked the organisations to find him a new residential placement.
68. The Council re-assessed Mr R’s needs before he left hospital. He went to the Coach House Care Home for a trial period so the Care Home could find out if they could provide Mr R with the right care.
69. The assessment shows he did not have any nursing needs which would need a Nursing Home placement. His primary needs were around prompting self-care, to eat and to take medication which he forgot because of dementia. The assessment also recognised Mr R sometimes showed challenging behaviour and could be abusive.
70. As mentioned, the Coach House Care Home is a specialist placement for those with dementia and other mental health issues. The decision to place Mr R at the Care Home was made by the Trust with the ICB overseeing his care under s117 aftercare. The funding for the placement was split between the Council and the ICB.
71. After the trial period, the Care Home agreed it could care for Mr R as a longer-term placement, but it would need extra funding for a one-to-one care package for Mr R. The ICB and Council agreed this on 19 May 2020, with a plan to review in three months. A review meeting took place on 20 August 2020 and it agreed the one-to-one care package should remain, with another review to take place in six months.
72. S117 of the MHA imposes a duty on health and social services to meet the health and or social care needs arising from, or related to, the persons mental disorder. This is known as s117 aftercare. S117 aftercare services must:
• meet a need arising from or related to the mental disorder for which the person was detailed; and
• have the purpose of reducing the risk of the person’s mental condition worsening and the person returning to hospital for the treatment for the mental disorder.
73. Section 33.7 of the Mental Health Act Code of Practice 2015 states Councils and CCGs should “maintain a records of people for whom they provide or commission aftercare and what aftercare services are provided.”
74. The ICB shares a statutory duty with the Council to provide, or arrange, s117 aftercare services for eligible service users in the area. The ICB told me it does not currently have a register in place, but one is held by the Council and the Trust who raise issues with the ICB when they arise. The ICB said it has a project underway to implement one of its own. As this is not in line with their statutory duty it is fault.
75. Mrs Q believes the organisations did not understand Mr R’s needs and this meant he was not cared for properly. I have seen evidence the ICB and Council considered Mr R’s needs and found a placement for him which was suitable. He had s117 aftercare reviews promptly. I can find no indication of fault with the care package funded by s117 aftercare and the role of the ICB and the Council in managing his continuing care funding.

Council response and safeguarding enquiry

76. Mrs Q complains the Council would not investigate her complaint and instead told her it conducted a safeguarding enquiry. The Council would not disclose the results.
77. Under the Care Act 2014 section 44, the Council’s Safeguarding Adults Board must arrange a Safeguarding Adult Review when an adult in the area dies because of abuse or neglect, whether known or suspected, and there is concern partner agencies could have worked more effectively to protect the adult. The Safeguarding Adult Review is used to help organisations learn lessons for the future.
78. Mrs Q made a formal complaint to the Council on 4 January 2021. She told them she felt if the doctor and Care Home acted quicker Mr R might still be alive. She told the Council she wanted to know if there was anything which should have been done to prevent her brother’s death.
79. On 8 January 2021, the Council opened a safeguarding enquiry and identified its lines of enquiry. On 28 January 2021 it wrote to Mrs Q to tell her it would not respond to her complaint until after the safeguarding enquiry was complete.
80. Mrs Q contacted the Council again on 20 July 2021 as she had not had a response. She told them she had raised a complaint with the Care Home direct because she had not had answers to her concerns. On 16 August Mrs Q sent the Council a copy of the Care Home manager’s response to her complaint. She was unhappy they had refused to answer some of her questions.
81. On 9 November 2021, the Council wrote to Mrs Q to give her the findings of the enquiry; the allegations were unsubstantiated. Mrs Q remained unhappy and contacted the complaint department again and asked for copies of all Mr R’s records. The Council refused her request. Mrs Q made another complaint to the Council and asked them for more details on the safeguarding enquiry. The Council wrote to her on 11 March 2022 and explained it could not give her any more information or respond to her complaint. It advised her to contact the Information Commissioner’s Office (ICO) if she was not happy with its decision about not sharing Mr R’s records with her.
82. SCIE guidance on Safeguarding Adult Reviews states the enquiry should consider what happened, any errors or problematic practice found and what could have been done differently. It should also look at why those errors occurred and if there are any explanations unique to the case and how these may be applied to future cases. Finally, it should decide if it needs to take action to prevent similar harm in future cases. The Council has a detailed adult safeguarding policy which advises how a Safeguarding Adult Review should be conducted.
83. I have reviewed the Council’s safeguarding enquiry documents and see it was completed in line with guidance. There were delays in the process due to COVID-19 pressures on Council staff and a change of role by the staff member leading the enquiry. The Council explained this to Mrs Q and apologised for the delay. It worked to complete the enquiry as quickly as possible.
84. I cannot disclose further information for the same reasons provided by the Council. Mrs Q will need to speak to the ICO about the Council’s decision if she is unhappy. I appreciate this has been a frustrating process for Mrs Q and she has been caused concern by the lack of disclosure, but it is not for the Ombudsmen to question the Council’s reasons not to disclose as this is not in our remit. I can find no indication of fault with the Council’s safeguarding enquiry.

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Agreed actions

85. The Ombudsmen recommended and the Care Home agreed to the following actions.
86. Within one month of the date of the final decision, the Care Home will write to Mrs Q and acknowledge the faults identified by the Ombudsmen and apologise for the avoidable distress and frustration this caused her both at the time of the events and in the local complaint’s resolution process. A copy of this should be sent to the Ombudsmen.
87. Within two months of the date of the final decision, the Care Home will issue a briefing note to all staff which:
• Reminds staff of the requirements related to record keeping as outlined in Regulations 9 and 17 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
• Reminds staff of the importance of accurately recording nutritional intake including what food or drink is consumed and the amounts given
88. The Care Home should provide a copy of the briefing note to Mrs Q and to the Ombudsmen in the same time frame.
89. The Care Home should conduct an audit of its current resident’s records to ensure the necessary care plans are in place with relevant review dates properly recorded and diarised.
90. Within six months of the date of the final decision, the ICB should Provide evidence to the Ombudsmen it has completed the project to implement a register of those it is providing S117 aftercare services too

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Final decision

91. I partly uphold Mrs Q’s complaint. I found fault which led to an avoidable injustice to Mrs Q. The agreed actions will provide a suitable remedy.

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Investigator's decision on behalf of the Ombudsman