Humber NHS Teaching Foundation Trust (18 002 657b)

Category : Health > Other

Decision : Upheld

Decision date : 25 Sep 2019

The Ombudsman's final decision:

Summary: Mrs C complains about the care Mrs D received while in a Care Home. The poor care led to pressure sores, dehydration and weight loss. The Ombudsmen uphold the complaint. We find fault from both the Care Home and a District Nurses Team in the advice and care around pressure damage. We also find other instances of poor care and record keeping by the Care Home. We have made recommendations.

The complaint

  1. The complainant, (whom I shall refer to as Mrs C), complains on behalf of her mother, Mrs D, about Mrs D’s stay at the Care Home. She complains that:
      1. at the beginning of her stay, Mrs D developed pressure sores, lost weight and became severely dehydrated.
      2. During the whole stay they witnessed evidence of poor care, such as:
    • carers not brushing Mrs D’s teeth;
    • carers sometimes not changing bedsheets after bed-wetting;
    • carers not turning Mrs D as often as stipulated in the care plan.
  2. My investigation has also looked at the actions of the District Nursing Team in relation to the pressure sore complaint.

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The Ombudsmen’s role and powers

  1. The Local Government and Social Care Ombudsman investigates complaints about adult social care providers. We decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. Where something has gone wrong we refer to those actions as ‘fault’. (Local Government Act 1974, sections 34B, and 34C, as amended)
  2. The Health Service Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’ in the delivery of health services. We use the word ‘fault’ to refer to these. If there has been fault, the Health Service Ombudsman considers whether it has caused injustice or hardship. (Health Service Commissioners Act 1993, section 3(1))
  3. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18ZA)
  4. 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

  1. As part of the investigation, I have:
    • considered the complaint and the documents provided by Mrs C;
    • made enquiries of the care provider and considered its response, including the Care Home’s detailed records;
    • considered the District Nurse Team’s records and policies;
    • considered the records of a dietician;
    • considered records from the local Health Centre;
    • considered the local Council’s records of its safeguarding investigation;
    • sought clinical advice;
    • spoken to Mrs C;
    • taken into account the comments of the care provider, NHS Trust and Mrs C on my draft decision.

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What I found

  1. The National Institute of Clinical Excellence (NICE) publish guidance: ‘Pressure ulcers: prevention and management’. This guidance is for healthcare professionals who care for people at increased risk of developing pressure ulcers, for example those with limited mobility. It says:
    • District nurses should carry out and document an assessment of pressure ulcer risk for adults receiving community care, especially those at high risk.
    • Repositioning should be encouraged, for adults at high risk, at least every four hours.
    • Pressure redistribution mattresses and chair cushions should be used for adults in community care settings with existing pressure damage.
    • Community nurses should develop and document a personalised care plan.

The District Nurse Team

  1. The Trust that the District Nurse Team is part of has its own Pressure Ulcer Prevention and Management Policy and Procedure, which says:
    • ‘… Persons will have their risk of developing pressure ulcers reassessed after a surgical or interventional procedure or after a change in their care environment following a transfer.’
    • Persons at risk of developing pressure ulcers, who are unable to reposition themselves, will have a repositioning schedule.
    • Nurses should order equipment and give advice about positioning after the first planned contact.
    • Carers should be educated in the use of equipment and details of the care plan to maintain skin integrity, or prevent further deterioration of the pressure ulcer.
  2. The Trust has a Confidentiality Code of Conduct. The Code says ‘[p]atients must be made aware that the information they give may be recorded, may be shared in order to provide them with care, and may be used to support clinical audit and other work to monitor the quality of care provided’.
  3. The Nursing and Midwifery Council’s Code of Conduct says nurses must ‘keep colleagues informed when you are sharing the care of individuals with other health and care professionals and staff’.

Safeguarding vulnerable adults

  1. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. This is called safeguarding.

What happened

  1. Mrs D is an elderly woman who lives with her husband (Mr D). She has dementia and a digestive illness. In the summer of 2017 a Community Occupational Therapist assessed Mrs D, including for pressure damage, diet and incontinence.
  2. Mrs C and Mr D arranged for Mrs D to go to the William Wilberforce Care Home (the Care Home) for a one-week respite break, beginning 1 November 2017.
  3. In late October, Mrs C asked the NHS’s District Nurse Team to visit Mrs D because of a pressure sore on her heel. District Nurses visited. They noted a suspected deep tissue pressure sore on Mrs D’s left heel and a blanching area to her hip. Her sacrum was reddened but unbroken. The Nurses referred Mrs D to a dietician, due to weight loss. They ordered a bed, mattress and pressure cushion, with the bed and mattress to be delivered to the Care Home.
  4. Mrs D’s family completed a pre-assessment form for the Care Home. This noted she was at high risk of pressure sores and needed specialist equipment, which the District Nurse Team was ordering. It also noted she was on a pureed diet, with no white flour or seeds.
  5. Mrs D moved to the Care Home on 1 November. The Care Home’s admission records note:
    • it could not weigh Mrs D because it would be unsafe for her to use the weight chair.
    • Mrs D needed a soft food diet. It listed her food preferences.
    • Mrs D needed ‘full assistance’ with feeding/drinking, personal care, moving and handling. A dietician contacted the Care Home soon after her admission.
    • Nurses were to visit for pressure checking and to apply dressings.
  6. The care provider says it knew, when Mrs D came to it (from her “Waterlow score”) that she was at high risk of pressure damage. But its first record of a Waterlow score is on 15 November. Waterlow scores are a way of risk assessing pressure damage. I can see the district nurses had assessed this at the time Mrs D was admitted. There is no record in either organisations records of sharing of this information on Mrs D’s admittance.
  7. Commenting on my draft decision, the care provider says, when Mrs D moved to the Home, it soon realised her care needs were higher than thought; especially around her ability to weight bear. But I can see no record, in the early weeks of Mrs D’s stay, that it raised these concerns with the family.
  8. An entry in the Care Home’s daily record for 2 November notes:

‘[Mrs D] has had a good day…sat out in her wheelchair in the lounge through the day’.

  1. District Nurses visited Mrs D on 2, 4, 5, 6 and 7 November. They noted her bottom remained red with a small broken area. The Nurses redressed that area for protection.
  2. On 8 November a Nurse visited. Mr D was there. The Nurse noted Mrs D was staying in the Care Home for an extra week, to allow time for the wounds to heal. The records say the Nurse advised carers they would visit again in two days. But they should contact the Team if they had any concerns.

On 10 November Mr D visited. The Care Home’s record notes:

    • this meant Mrs D ‘…spent most of the day sat in her wheelchair’.
    • Staff noted Mrs D’s sacrum area had been bleeding. They informed the District Nurse Team.
    • ‘D[istrict] N[nurse] spoke with staff and agreed it would be a good idea to put [Mrs D] on bed rest after her lunch instead of sitting in her wheelchair.’
  1. On 10 November, the Care Home created a night care plan asking carers to turn Mrs D every two hours and to wash her bottom and apply cream. A care note during that night noted Mrs D’s bottom had been getting better, but that night it had worsened.
  2. A District Nurse visited on 11 November. She found Mrs D in her wheelchair. A senior carer said they would put Mrs D in bed in the afternoon. A morning care note confirms that was the Care Home’s plan.
  3. The Nurse revisited in the afternoon with a colleague, to check the pressure areas. Her notes say Mrs D’s wounds had worsened. She advised the Care Home to only get Mrs D up out of bed for mealtimes and to nurse her from side to side. And also to ask Mrs D’s family to bring in her pressure cushion. The Care Home’s daily note of this advice is consistent with the Nurse Team’s record.
  4. The Nurse also:
    • referred Mrs D to a Tissue Viability Nurse (TVN).
    • Agreed to carry out daily visits for monitoring.
    • Noted a need for a reassessment of the sores every two weeks.
    • In line with the Trust’s policy, alerted the local Council’s safeguarding team about the pressure sores. And also concerns about what would happen when Mrs D went home.
    • Advised the Care Home to start a turning chart.
  5. The Nurse visited Mrs D on 12 November. She noted that one of the wounds had lessened and the other had not worsened.
  6. On 13 November the District Nurse visited with a TVN. The TVN’s view was the pressure wound had got worse due to pressure while Mrs D was sitting in a wheelchair. He also noted moisture lesions.
  7. The District Nurses’ records note:
    • the Nurses had by then advised the Care Home to turn Mrs D every two hours during the day and four hourly at night.
    • The District Nurse Team ordered a ‘high risk static cushion’.
    • The Nurse advised Mr D about the referral to the Council’s Safeguarding Team.
    • The Nurse also noted the recommended two hourly turn was 45 minutes overdue at the time of their visit. So they asked Care Home staff to make sure they kept to the plan.
    • The District Nurse Team spoke to Mrs D’s daughter and advised they might need to have a meeting to discuss the risks around her discharge home.
  8. On 14 November Mrs C visited . She says she was shocked by how Mrs D seemed. Mrs C describes Mrs D as ‘…was grey, waxy, mouth open, not responsive and frail. Near death. Clearly dehydrated and bordering on starvation.’
  9. On 15 November the Care Home carried out risk assessments in mobilisation, neglect and wheelchair use. The Care Home also completed care plans in:
    • Moving and handling. This noted the need for recorded turns. And a need to check the sores and report any changes promptly.
    • Skin care. This noted the need for carers to offer Mrs D at least 1200 millilitres (ml) of fluid per day. There is some confusion over this total as some of the sheets showing daily totals note this is the target. But some others note a target of 2000ml.
    • Continence. This included instructions in how to clean Mrs D’s skin to avoid further damage.
    • Medication.
    • Nutrition. This required measurement of food and fluids carers gave Mrs D and noted ways to encourage Mrs D to eat.
  10. The care provider says it completed these care plans then, due to an increase in Mrs D’s risk of pressure damage. The Care Home began to keep fluid intake charts for Mrs D from 15 November.
  11. On 16 November an occupational therapist (OT) arranged an emergency Best Interests Meeting. The record of the meeting noted Mrs D needed regular changes of her dressing; so it was best she stayed at the Care Home. The family had lost trust in the Home; but a social worker advised there was no availability elsewhere.
  12. A Nurse’s note of a visit on 17 November observed that staff had logged food intake, but not type of food, how much, and how they were giving it to Mrs D. The Nurse also noted there was no record of Mrs D having had breakfast. A different Nurse visited later and reiterated to carers the need to document every action. She also spoke to Mrs C.
  13. A Nurse’s record on 23 November notes carers advised her that Mrs D was eating more. The Care Home’s records have several notes after this that Mrs D was eating well.

The Council’s safeguarding investigation

  1. The Council’s record of the safeguarding referral notes:
    • The District Nurse making the referral advised that a carer had been ‘very honest’ in noting Mrs D had been left to sit in a chair from morning to tea. The Nurse’s view was this caused the pressure areas to worsen.
    • Mrs D also had a soaking wet incontinence pad.
    • Ms D’s other daughter (Ms E) said that she saw Mrs D sitting in her wheelchair daily.
    • The Care Home told Ms E the family could take Mrs D’s pressure cushion home, as it had an identical one. The Care Home later said its cushion did not provide the same level of protection from sores.
  2. The Council’s report of its safeguarding investigation noted:
    • The District Nurses visited Mrs D daily. By 19 November their records noted Mrs D’s pressure sores were improving. That improvement continued afterwards.
    • The District Nurses had provided little advice for the Care Home to follow.
    • On 11 November (when the pressure sores worsened), the Nurses had not written any advice in a communications book.
    • The Care Home started using turn re-positioning charts from 12 November. These confirmed carers had followed advice from the Nurse on turning Mrs D.
    • The Care Home started keeping a food intake chart from 1 December. On occasion it had not been fully completed.
    • Care Home staff had been put on training in pressure care and other issues.
  3. In late December 2017 Care Home staff met Mrs C and Mr D for a review meeting. The care provider’s record of that meeting noted:
    • The family’s concerns about the timing of meals.
    • Family concerns that, when visiting, they had to go looking for staff to turn Mrs D.
    • The Care Home manager asked the family to provide a time and date for an alleged incident when they said they witnessed carers turning Mrs D on a wet bed.
    • The Care Home’s view was the problems were caused by the lack of communications from the Nurses.
  4. On 4 January 2018 a dietician visited Mrs D. Her view was that it was not safe to weigh Mrs D, but checked her body mass index (BMI). She had no concerns and noted Mrs D’s BMI was the same as when she had reviewed Mrs D at home.
  5. The District Nurses were checking the Care Home’s daily records. On 12 January a Nurse noted some problems with dates and entries with the food and fluid charts on 8 and 9 January. A carer apologised that she had forgotten to write on the charts. The Nurse reminded carers to record food and fluid intake, even if Mrs D’s family had fed her.
  6. On 12 January, the Care Home responded to a complaint from Mrs C. This noted:
    • It knew Mrs D was high risk when it admitted her. Its care was consistent with caring for somebody at high risk.
    • On admission, Mr D said he would take the pressure cushion home, as the Care Home had its own.
    • The District Nurses were leading on the pressure area check. But their instructions were sparse; with no management plan.
    • It was only on 11 November, when a dressing was removed, that they saw how badly the sore had developed.
    • After the Nurses’ interventions in November, its view was Mrs D had become ‘very high risk’. It was then it started to record positional changes and fluid intake on paper.
    • During the three-day period 10 – 13 November, senior carers or management should have informed family of developments with the pressure sore. It apologised for any distress caused by not being informed.
    • Its records showed that it was regularly giving Mrs D fluid. Most checks showed Mrs D had good urine output. So there was no evidence to support Mrs C’s claim Mrs D was ‘clearly dehydrated’.
    • It disputed any fault with food intake. It could not see missed meals from its notes, apart from one instance of a missed breakfast. It apologised for that.
  7. Mrs C complained to the Local Government and Social Care Ombudsman. In response to my enquiries, the Care Home provided its detailed records of its care. From my close analysis of these records I have noted the following issues:

Fluid charts

  1. The Care Home kept these charts from 15 November, after advice from the District Nurses. The records are comprehensive. They include a section to record urine output (measured by pad changes). There is a separate record noting the daily totals. I see no significant fault with these records.
  2. I have checked the daily records for the time before the Care Home started the fluid charts. These record three or four pad changes daily. They also record the fluid carers gave Mrs D. This ranges from 400 to 1050 ml. But the charts show that, in the four days from 11 November, the Care Home’s record of Mrs D’s fluid intake was: 200 ml, no record, ‘offered drinks’ and 50 ml/’sips’. Those same records also show that on the three days, from 12 November, Mrs D had her pad changed: twice, once and two times. On 12 (once) and 14 November (twice), the records note Mrs D’s pad was dry.

Food intake

  1. These were largely kept well, after further advice the Nurses gave. But there are a few omissions. The records note when Mrs D’s family gave her food, after district nurses had asked carers to do this.

Turn chart

  1. The Care Home kept this chart from 12 November. It shows carers largely turned Mrs D to the Nurses’ schedule. But there are a few records:
    • of turns at night outside the four-hour schedule. Most of these are by a few minutes. But on three occasions the carers did not turn Mrs D for more than six hours.
    • Of daytime turns outside the two-hour schedule. Most of these are by a few minutes. But on two occasions they were late by an hour or more (the longest time was three hours 10 minutes between turns).
  2. Before the Care Home started the chart, there are only occasional records of turning Mrs D, or her lying on her side. The morning care routines for those days note that carers gave Mrs D assistance to get up. In response to my draft decision, the care provider noted carers would also have been providing pressure relief when they provided Mrs D with continence care. But the records themselves do not support this. I checked a two day sample of these records. On 2 November there is one instance of no records for a nearly five hour period. On 3 November, there are gaps of just under eight hours between records and another record of over five hours.

Daily records

  1. The main daily running records are electronic records. The software seems to allow users to add standard statements about care given. The care provider has also sent me some hand-written records, kept between 17 and 30 November. It says it kept these as the district nurses did not have access to the electronic records. The handwritten notes record some instances of care (for example incontinence, leading to a bed change, or giving Mrs D her drink), that are not in the main records. The handwritten record reminds carers those records are not a substitute for the electronic records.
  2. Both sets of records note changing of bed linen because of a wet bed. Carers have made records of this task throughout the time Mrs D was at the Care Home.
  3. The main place where care given is recorded in the daily record, is in a section headed ‘morning routine’. There are occasional records of other care records such as ‘evening routine’, or bathing or shower. I have included these in my analysis. I have also included the handwritten records.
  4. Mrs D was in the care home for around 168 days. Of those days, there is no morning routine, or other record of personal care (eg, washing, showering, dressing - although there are separate records for meals, turning and continence care), on 75 days.

Oral hygiene

  1. One of the standard statements in the morning routine is of Mrs D needing assistance to brush her teeth. On the 93 days where there is a morning routine record, the statement about brushing teeth has not been selected on 40 occasions. So this makes a total of 115 times when carers have not selected this statement.
  2. On 16 March 2018, the Care Home introduced a new care plan about Mrs D’s oral hygiene. It is not recorded why it introduced this plan at this time. It notes Mrs D usually did not like having her teeth brushed and needed lots of encouragement (although the records have no earlier notes of this). It says that Mrs D needed encouraging to brush her teeth once a day. Mrs C says Mrs D was not able to independently brush her teeth.
  3. The plan stipulated that carers start an administration record about oral hygiene. But the medical administration records the care provider has sent me only have this oral hygiene record for the period 16 to 19 April. There are no records of oral hygiene care, in this record, or in the daily care records, on 15 of the 30 remaining days Mrs D was at the care home, after the care provider introduced the oral hygiene care plan.

Analysis

The District Nurse Team

  1. Mrs D had existing pressure damage. So my view is District Nurses should have worked with Care Home staff from her admission. This is consistent with the clinical advice the Ombudsmen have received. There is little evidence of shared working by Nurses, with the Care Home, until 12 November. I would have expected to see a record of Nurses advising Care Home staff on correct pressure relieving aids and positional changes from their first visit. This is consistent with NICE guidance and the Nursing and Midwifery Council’s Code. The Trust has its own policy that suggests Nurses should advise carers and advice of a repositioning schedule.
  2. I also note it was not until 13 November that the Nurses noticed Mrs D was not using the pressure relieving cushion their Team had ordered. They might have noticed this earlier with better communications with the Care omHHome.
  3. I would have expected to have seen evidence in the District Nurse Team’s records that it had advised Mrs D and her family they would need to share its records with the Care Home. That would have been consistent with the Trust’s Confidentiality Code of Conduct. It would have overcome any concerns they might have had about sharing information with the Care Home.

The Care Home

Turns

  1. There is evidence carers were not moving Mrs D as often as needed from the time it admitted her. I accept the District Nurses were leading on pressure care. But the Care Home was aware of Mrs D’s high risk of pressure sores. Guidance recommends people with high risk of pressure damage are turned at least every four hours. So I would have expected to have seen evidence the Care Home itself had considered, during its pre-admission planning, whether Mrs D needed regular turning, perhaps through a risk assessment or care plan. The care provider says it was aware of this need, although it does not document it until 15 November.
  2. There is some evidence that carers were turning Mrs D in bed, before 12 November. But records of this time do not show that carers were systematically turning Mrs D every four hours.
  3. There is also evidence that in the time after the Care Home introduced the turn chart, carers sometimes turned Mrs D late. This is infrequent, but does give some substance to the family’s assertion that at times they had to find carers to remind them to turn Mrs D.

The pressure cushion

  1. There is evidence carers sat Mrs D out during the early part of her stay; from:
    • the daily records which note this on occasions;
    • the morning routine records which say carers gave Mrs D help with getting up;
    • Mrs D’s relatives’ statements that they often saw Mrs D sitting out in a wheelchair.

By not itself considering Mrs D’s needs, the Care Home did not consider the risks of a worsening of Mrs D pressure damage.

  1. On admittance, Mrs D’s family brought in her pressure cushion. The family says this was not used until the pressure sores got worse. The Care Home says (in its complaint response, but not in its contemporaneous records) that it advised the family it had a cushion. The records do not say what the Care Home’s cushion was. And I can see no record of Mrs D using any cushion when carers sat her out. But I can see times when Mrs D was sat out in a wheelchair without a cushion.
  2. This suggests fault by the Care Home in:
    • its analysis of Mrs D’s need for the pressure relieving aids Mrs D’s family brought with them;
    • more likely than not, sitting Mrs D out without using a pressure cushion.

Pre-admittance checks

  1. Mrs D was only meant to be in the care home for a week. So my view is its pre-admittance risk assessments were appropriate for that anticipated stay, apart from not considering movement around pressure care. When Mrs D’s stay was extended, the Care Home created a new set of care plans, including around the pressure care.

Record keeping

  1. The daily care records of carers’ personal care were lacking. For a little under a half of the days Mrs D was in the Home, there is no record of a (particularly morning) care routine. There were also some omissions from the food intake chart.

Oral hygiene

  1. The Care Home’s records of oral care are particularly poor, with a total of 112 days out of 168 when it has no record of assisting Mrs D with brushing her teeth. It is unclear from the care notes why the Care Home introduced the oral care plan in March. But the records after this remained inconsistent.
  2. The care provider says Mrs D was reluctant to allow carers to brush her teeth. I can understand the challenges this will have led to. But I would have expected:
    • A daily record of trying to brush Mrs D’s teeth.
    • An earlier plan to consider how it would meet this unmet care need.

Dehydration

  1. A close examination of the records shows there was a period (11-14 November) where Mrs D’s fluid intake declined, as did her urine output. So, on the balance of probabilities, I agree with Mrs C that she was likely dehydrated on 14 November. The problem with the way the Care Home was recording fluid intake then was this information was not easily accessible. This likely explains why the Care Home did not pick up on this issue.
  2. Either side of that four-day period, I do not have the evidence to say Mrs D was dehydrated. I also do not have the evidence to make a finding on why Mrs D’s fluid intake declined between 11 and 14 November. Any findings on this would be speculative.

Bed changes

  1. Mrs C says they witnessed times when carers left Mrs D in a wet bed. I can see evidence throughout the records of carers changing Mrs D’s bed-linen, after they had dealt with her incontinence. So, without more specific evidence, I do not have the evidence to uphold this part of the complaint.

Injustice

Pressure care

  1. If there had been no fault from either organisation with the care of Mrs D’s pressure sores, it may be that the sores’ worsening from around 10/11 November may have been avoided or lessoned. The uncertainty about whether things might have been different, but for the faults, is an injustice.

Record keeping

  1. My view is the Care Home’s failure to keep adequate records led to uncertainty about whether all the care it provided was adequate. And whether any of the concerns the family had, about for example, Mrs D’s dehydration, might have been avoided. That uncertainty might have been allayed by better records.
  2. In response to my draft decision, the care provider recognises the records were inadequate. It says this was partly because of the software it was using. It says it has now changed its record keeping software.

Dehydration

  1. We do not know why Mrs D’s fluid intake declined in mid-November. But the Care Home does not seem to have noticed the pattern of reduced fluid intake and urine output. My view is if it had noticed, it would earlier have taken measures to encourage Mrs D to take more fluid. More likely than not, this will have prevented some distress for Mrs D.

Oral hygiene

  1. There was a particular problem with oral hygiene. Inadequate records meant a delay in developing a plan to deal with the issue. This will have been undignifying and upsetting for Mrs D.

Mrs D’s family

  1. The care provider has acknowledged an instance of poor communication with Mrs D’s family. It will also have been upsetting for them to have to advocate for Mrs D about some of the faults I have identified in this statement. That injustice demands its own remedy.

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Recommendations

  1. I recommend, that within a month of my final decision, the organisations under complaint make:
    • a combined symbolic payment of £300 as a reflection of the injustice the fault around the pressure care caused Mrs D.
    • each organisation pays half of this figure.
    • an apology to Mrs D about these faults.
  2. Within three months of my final decision, I recommend the District Nurses Team include in its policy and procedure a clarification around joint working with care homes. I recommend it consider how it can include the NICE guidance and Nursing and Midwifery Code within its own documents.
  3. I also recommend it reminds nurses of the Trust’s policy on advising patients and/or their families of the possibility of sharing information. And a reminder of the need to make a note they have done this.
  4. I ask that it then reports back to the Ombudsman.

Other faults by the Care Home

  1. I recommend, that within a month of my final decision:
    • the Care Home pays Mrs D £500, as a symbolic payment for the other faults I have identified around care and record keeping.
    • It sends Mrs D and her family a letter of apology.
    • It makes Mrs C a payment of £200 to reflect her own distress and the time and trouble she was put to.
  2. Within three months of my final decision, I recommend the care provider:
    • Write a policy for its carers outlining the importance of accurate record keeping.
    • Review the issues identified here and report back to the Ombudsman how it can improve its identification of issues such as Mrs D’s dehydration and poor oral hygiene. The aim of the review should be to identify how it can earlier take steps to address issues that arise during a resident’s stay.

I ask that it then report back to the Ombudsman.

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Final decision

  1. I uphold the complaint against both the NHS Trust and the care provider as I have found fault that has caused Mrs D and Mrs C an injustice. I have made recommendations.
  2. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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Investigator's decision on behalf of the Ombudsman

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