Hollymere House Care Home (18 016 698a)

Category : Health > Other

Decision : Not upheld

Decision date : 27 Aug 2019

The Ombudsman's final decision:

Summary: Mr S complains the Home failed to provide adequate care to his late mother-in-law Mrs D, causing distress to Mrs D and her family and potentially contributing to her death. The Ombudsmen’s view is there is no evidence of fault causing injustice to Mrs D.

The complaint

  1. Mr S complains about the care provided to his late mother-in-law Mrs D at a care home run by H C One Ltd, Hollymere House Care Home (the Home), in March 2018.
  2. Mr S says poor care including inadequate management of hydration needs led to Mrs D’s admission to hospital on 31 March 2018. He says the hospital found Mrs D had grade 2 pressures sore on her buttocks and faecal impaction. Mr S also believes the Home was wrongly treating Mrs D as an ‘end of life’ patient. Mr S complains staff at the Home spoke in an inappropriate way to Mrs D as a dementia patient, and that the Home dismissed this part of his complaint.
  3. Mr S says these failings caused avoidable distress to Mrs D and he believes they may have contributed to her death. He says Mrs D’s poor care greatly affected his wife (Mrs D’s daughter) and she has needed medication from her GP.
  4. As an outcome to his complaint Mr S wants the Home to acknowledge the failings in care he believes occurred, and to change its practices and procedures for the benefit of future residents and their families. He is also seeking financial redress for the suffering caused to Mrs D and her family.

Back to top

The Ombudsmen’s role and powers

  1. 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)
  2. The Ombudsmen investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C and Health Service Commissioners Act 1993, section 3(1)). 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.
  3. 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.
  4. 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))
  5. 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)

Back to top

How I considered this complaint

  1. As part of my investigation of this complaint I have considered:
  • Information Mr S provided verbally and in writing
  • Written information from the Home and the hospital Mrs D went to
  • Relevant legislation and guidance
  1. I took clinical advice from a nurse. I asked the clinical adviser to give advice based on relevant standards and guidelines and established good practice for the circumstances. I considered the clinical advice as part of the evidence.
  2. All parties had the opportunity to comment on a draft of this decision and I took their comments into account before making a final decision.

Back to top

What I found

  1. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
  2. Regulation 10 aims to ensure people who use services are treated with dignity and respect.
  3. Regulation 14 aims to ensure people who use services have adequate nutrition and hydration to sustain life and good health. It also reduces the risks of malnutrition and dehydration while they receive care and treatment.
  4. Regulation 17 aims to ensure providers have systems and processes that ensure that they can meet their duties. This includes the requirement to keep accurate, complete and detailed records about each person using the service.

Pressure sores

  1. The National Institute for Health and Care Excellence (NICE) has issued a clinical guideline on Pressure Ulcers: prevention and management (CG179, April 2014). This sets out the steps healthcare professionals should take to assess, prevent and treat pressure ulcers.

Nutrition and hydration

  1. The National Institute for Health and Care Excellence (NICE) issued a clinical guideline called Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition (CG32) in February 2006. This states that healthcare professionals should ensure that care provides ‘food and fluid of adequate quantity and quality in an environment conducive to eating’.

Background events

  1. Mrs D, aged 84, was admitted to hospital from her nursing home on 31 March 2018. She had a medical history of Parkinson’s Disease and Alzheimer’s Disease. The Home was concerned that Mrs D had significantly decreased her eating and drinking over 24 hours and she was very lethargic. She went to hospital by ambulance and was admitted to the Emergency Department at 14:30. When doctors assessed Mrs D they suspected she had pneumonia. She was very unwell and doctors told Mrs D’s daughter that she might not survive.
  2. Mrs D was moved from the Emergency Department to a ward at 17:40 on 31 March. When staff assessed her on the ward they noted she had a grade 2 pressure sore on her sacrum (base of the spine). There was no evidence or documentation about pressure sores from the Emergency Department.
  3. Mrs D remained in hospital and died on 29 April 2018. The causes of her death were Alzheimer’s Dementia, Parkinson’s Disease and Frailty.
  4. Mr S complained to the Home about the care Mrs D had received there.

Management of hydration needs

  1. Mr S complained that Mrs D was severely dehydrated when ambulance paramedics attended on 31 March 2018 and when she later arrived at hospital.
  2. In its complaint response the Home outlined the steps taken to manage Mrs D’s hydration. It said there was a fluid dip on the day before her hospital admission and on the day of her admission. The Home commented that Mrs D was vomiting which would contribute to dehydration in a frail patient. The Home provided more information in its letters to the Ombudsmen. It said staff handed over information when Mrs D’s fluid intake was below her recommended target, but the Home was unable to provide evidence of any direction actions taken as a result of this.
  3. The Home said it would be moving its daily clinical walk around from the morning to between 14:00 to 15:00, to give an opportunity to identify residents whose food or fluid intake had dropped, and to provide enough time to take action and to aid with recovery.

Analysis

  1. Maintaining fluid balance in a patient is important to avoid complications such as dehydration, which can have serious clinical consequences. Staff must maintain accurate records including oral fluids taken, urine passed, and vomiting. Nurses and carers should always report any significant abnormalities in a patient’s fluid records. Review of fluid balance charts is not the only element in assessing fluid balance and hydration. Other elements include clinical assessment, increase or decrease in body weight, and review of bloods.
  2. Mrs D’s targeted fluid intake was 900mls per day. This was not clearly identified on all the fluid intake and total fluid charts kept by the Home.
  3. I have reviewed the 24hr fluid charts for the week leading up to Mrs D’s admission to hospital. Her fluid intake target was met on 26, 27 and 29 March. Her fluid intake was slightly under target on 25 March (860mls), and was under target on 28 March (635ml) and 30 March (535ml).
  4. It is not clear from the Home’s records whether staff took any action on the days when Mrs D’s target fluid intake levels were not reached. As outlined above, the Home said staff handed over information when Mrs D’s fluid intake was below target, but it could not provide any evidence of direct actions taken as a result. This amounts to fault in the Home’s record keeping for this aspect of Mrs D’s care.
  5. There is evidence in the Home’s records that staff took steps to encourage Mrs D to take oral fluids, and staff offered fluids in accordance with the Home’s policy on Nutrition and Hydration. Staff at the Home recorded when Mrs D declined fluids that were offered to her. A person can be encouraged to drink but cannot be made to do so. Mrs D declined fluids on 30 March. This is likely to have been due to her nausea and vomiting and being generally unwell.
  6. Having carefully considered all the evidence, including clinical advice, I have concluded that, overall, the Home took adequate steps to monitor and manage Mrs D’s fluids in the period leading up to her hospitalisation. There was fault in the Home’s record keeping as it is not clear whether staff took action on days when fluid levels were not reached. I do not consider this fault led to an injustice to Mrs D.

Pressure sores

  1. Mr S complained the hospital found grade 2 pressure sores on Mrs D’s buttocks after her transfer to hospital. He said she had had three weeks of enforced isolation and confinement at the Home during a recent flu outbreak. He said she spent most of the time in bed, and despite a pressure cushion on a chair in her room, he had no knowledge of her being sat out in the chair over that three-week period. Mr S also said Mrs D was left in a wet pad and clothing for a prolonged period during a protected mealtime.
  2. The Home said Mrs D was at significant risk of pressure damage due to her frailty, low weight and incontinence. It set out the steps taken to provide skin and pressure area care. It said there were eight position changes on the day before she went to hospital, and four on the day she was admitted. It said staff recorded her skin was in-tact at 07:40 on 31 March. The Home said it could not categorically say her skin was in-tact when she left the Home to go to hospital. However, the Home was satisfied this aspect of her care was appropriate.
  3. The Home said for the vast majority of the time staff repositioned Mrs D within the recommended time interval of 4 hours. It said there was no evidence of the frequency of repositioning or pressure relief provided after Mrs D left the Home by ambulance until she was admitted to Ward 3 at the hospital in the late afternoon. In particular, the Emergency Department made no records about this aspect of Mrs D’s care.
  4. The Home said that in future, any resident being admitted to hospital would have a full check of their skin and staff would complete a body map before they go to hospital. The Home said this would enable it to provide reassurance to families about care delivery. The Home said completion of a body map would not cause any delay in the process of transferring residents to hospital as there is always a time period between calling for an ambulance and it arriving.

Analysis

  1. The NICE guidance on Pressure ulcers: prevention and management makes a number of recommendations including initial assessment, ongoing assessment, use of care plans, repositioning, and use of pressure re-distributing devices.
  2. Mrs D was identified as being at very high risk of developing pressure sores. The Home reviewed the risk assessment monthly and Mrs D remained at the same risk level throughout her time at the Home.
  3. The Home put a Care Plan in place in response to Mrs D’s risk of developing pressure sores. This included using a pressure relieving mattress and cushion, management of her personal hygiene, and 4-hourly repositioning. There is nothing in the Home’s records to indicate concerns about changes or deterioration in Mrs D’s pressure areas. The last visual observation of her skin, at 07:40 on the day of her admission to hospital, said her pressure areas were in‑tact.
  4. The Emergency Department did not make any records about damage to Mrs D’s pressure areas. The pressure damage was first noted when she was transferred to a ward late afternoon. The hospital told the Home that the pressure damage was likely to be due to Mrs D’s poor health and end-of-life changes in skin condition.
  5. I have concluded that the Home took appropriate steps to monitor and manage Mrs D’s risk of pressure damage. It is not possible to identify when the pressure sore developed. There was a gap in recording pressure area care and skin integrity whilst Mrs D was in the Emergency Department. I have concluded the Home’s actions were in line with the relevant NICE guidance. I have not identified any fault in this aspect of Mrs D’s care.

Faecal impaction

  1. Mr S complained that the hospital found Mrs D had faecal impaction.
  2. The Home said the hospital had confirmed there was no evidence of faecal impaction. The Home also said Mrs B opened her bowels regularly, at least once a day in the week leading up to her hospital admission, and on one occasion twice. The Home told us it carries out a weekly nurse review of bowel management, so staff can take any necessary action.

Analysis

  1. Bowel care is a fundamental aspect of nursing care. Records need to include evidence of assessment, care planning and review. It is established good practice that nurses and care staff record a person’s bowel activity daily. Many homes have adopted the Bristol Stool Chart, which classifies stool into 7 categories and can alert staff to any abnormalities or significant changes.
  2. The records for Mrs D show that she opened her bowels daily in the period leading up to her hospital admission, except for 19 and 25 March. However, staff did not document the type or consistency of her stool. It is not possible to say whether Mrs D was constipated in the period before her admission to hospital.
  3. However, the hospital has confirmed there was no evidence of faecal impaction.
  4. Based on all the available evidence, I have concluded the Home took appropriate steps to monitor and manage Mrs D’s bowels. Although the Home should have documented the consistency of Mrs D’s stools as well as the frequency of her bowel movements, this did not cause an injustice to Mrs D.

End of Life status

  1. Mr S complained that due to a change in GP, the Home wrongly put Mrs D on End of Life care. He said if they had not visited her on 31 March he felt she would not have survived that weekend.
  2. The Home told us it was treating Mrs D in accordance with directions from her GP. A Do Not Attempt Resuscitation Order was in place, but she was not deemed to be an end-of-life patient. The Home said this was clear from Mrs D’s GP records, interventions from a dietician, the continuation of regular medications, and the fact that the GP had not prescribed any anticipatory end-of-life medications. The GP wrote in the Professionals Communication Record that they did not feel Mrs D was at the point where anticipatory end-of-life medications were needed.

Analysis

  1. Having considered the available evidence, I have not seen any indication that Mrs D was being treated on an end-of-life pathway by the Home. It is clear that Mrs D was very frail at the time of these events. The hospital documented that when Mrs D was admitted to a ward on 31 March she was on an end-of-life pathway. It is possible that this information led Mr S to think the Home had put Mrs D on an end-of-life pathway before she was admitted to hospital. However, I have not seen any evidence that this was the case at the Home.

Communication with a dementia patient

  1. Mr S complained that staff communication with Mrs D was not appropriate for a dementia patient. He said that, for example, staff would lean over her and say ‘ccooee, is anybody there?’. He said the Home’s response to this issue was not adequate.
  2. In its formal complaint response the Home said it could not address this issue further without knowing the name of the member of staff involved or the date of the incident. The Home provided general assurances about staff training on supporting residents with dementia and delivering person-centred dignified care.

Analysis

  1. As outlined by the Home, it is difficult to investigate this issue in any detail without information about the member of staff concerned. The Home tried to provide Mr S with general reassurances about how it trains staff to support residents with dementia. Whilst I appreciate that Mr S and his wife have been caused distress, I do not consider that investigation of this issue can add anything to what the Home has already said.

Back to top

Decision

  1. There was no evidence of fault by the Home causing injustice to Mrs D.

Back to top

Investigator's decision on behalf of the Ombudsman

Print this page

LGO logogram

Review your privacy settings

Required cookies

These cookies enable the website to function properly. You can only disable these by changing your browser preferences, but this will affect how the website performs.

View required cookies

Analytical cookies

Google Analytics cookies help us improve the performance of the website by understanding how visitors use the site.
We recommend you set these 'ON'.

View analytical cookies

In using Google Analytics, we do not collect or store personal information that could identify you (for example your name or address). We do not allow Google to use or share our analytics data. Google has developed a tool to help you opt out of Google Analytics cookies.

Privacy settings