Summary: Mr X complains Chandler Court failed to meet his mother’s needs properly after she had a stroke on 6 May 2023, resulting in her being left for six hours before calling an ambulance. Care UK accepts Chandler Court should have checked Mrs Y earlier in the day for signs of a stroke. It says it has taken action to ensure this does not happen again. Care UK needs to confirm the action it has taken. It also needs to make a symbolic payment to Mrs Y.

The complaint

1. The complainant, whom I shall refer to as Mr X, complains Chandler Court failed to meet his mother’s needs properly after she had a stroke on 6 May 2023, resulting in her being left for six hours before calling an ambulance

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The Ombudsman’s role and powers

2. We 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. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)

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How I considered this complaint

3. I have:
• considered the complaint and the documents provided by Mr X;
• discussed the complaint with Mr X;
• considered the comments and documents Care UK has provided in response to my enquiries;
• considered the Ombudsman’s guidance on remedies; and
• shared a draft of this statement with Mr X and Care UK, and taken account of the comments received.

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What I found

Key facts

4. Chandler Court is a nursing home run by Care UK Community Partnerships Limited (Care UK). Mr X’s mother, Mrs Y, went to live in Chandler Court in August 2022, having spent two months in hospital following a stroke. She has dementia and other medical conditions, including a rectal prolapse.
5. A GP visited Mrs Y on 4 May, as she had said her legs felt as though they were giving way. The GP arranged for some blood tests and prescribed a pain-relieving gel for her legs and knees, and medication for high blood pressure.
6. When Mr X visited his mother in the afternoon of 6 May he was concerned about her condition. He raised his concerns with the nurse on duty, who agreed to monitor Mrs Y and call NHS 111 if she deteriorated. Mr X went home at 15.44 and discussed his concerns with his partner. They both returned to Chandler Court at 16.55. When Mr X’s partner tried to change Mrs Y into her nightclothes, she noticed her left arm was weak and she wasn’t moving her left leg at all. They raised their concerns with the nurse again, who checked Mrs Y’s movements.
7. Chandler Court’s records for Mrs Y’s condition on 6 May say, after her family raised concerns:
• the nurse did a FAST (Face, Arms, Speech, Time) assessment for a stroke and noted Mrs Y could not raise her left arm and had slurred speech;
• an ambulance was called (Mr X says he did this);
• the paramedics arrived around 18.10 and took Mrs Y to hospital.
8. When Care UK replied to Mr X’s complaint in July, it said:
• In the morning of 6 May a care worker told the nurse in charge that Mrs Y’s rectal prolapse had come down. Mrs Y had been complaining of back pain and feeling uncomfortable. A permanent member of staff confirmed that on doing welfare checks Mrs Y had been leaning to one side. They felt Mrs Y was leaning over to avoid putting pressure on the area.
• Staff noted Mrs Y could be confused at times, because of her previous stroke, but she was slightly more confused on 6 May. However, they said Mrs Y’s speech was not slurred and her face was not drooping. Mrs Y talked and responded to staff throughout the day.
• The complaints Mrs Y had made ’about her legs feeling as though they were giving way (on 4 May) may have contributed to her poor mobility on 6 May. The first dose of blood pressure medication received on 5 May may have contributed to Mrs Y not feeling herself.
• Mrs Y had maintained her weight since moving to Chandler Court, so it was not formally recording her food/fluid intake. However, Mrs Y had some of her breakfast on 6 May. She did not feel up to going to the dining room at lunchtime and did not eat any lunch when it was taken to her room. It was not unusual for someone to skip a meal if they were not feeling themselves.
• The nurse had listened to them on 6 May and immediately called an ambulance.
• The nurse used a hoist to get Mrs Y into her bed, as she had been complaining about her legs giving way.
• It apologised because Chandler Court had not kept in contact with the hospital or the family after Mrs Y went into hospital.
9. As Mr X was not satisfied with Care UK’s response, he asked it to review its response. When Care UK replied in August, it said:
• The nurse should have monitored Mrs Y for signs of a stroke earlier in the day, given her medical history.
• It could not say what difference this may have made to the severity of Mrs Y’s stroke.
• It apologised for the distress caused.
• It would ensure Chandler Court learned from this and improved the relevant services.
10. When the Care Quality Commission (CQC) inspected Chandler Court in February 2023, it found it required improvement overall, including to make it safe and well-led. It found it was good in terms of being effective, caring and responsive. Its report published in March 2023 said:
• “People did not always have risks to their health and welfare effectively managed. Care Plans and risk assessments did not always reflect guidance and advice from professionals. People did not always receive their medicines in line with the prescription. Audits were not always effective in identifying where actions were needed to improve the assessment and monitoring of risks and did not effectively monitor the outcomes for people.”

Did Care UK’s actions cause injustice?

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. CQC has issued guidance on how to meet the fundamental standards below which care must never fall. Regulation 12 requires care providers to provide care and treatment in a safe way.
12. Care UK accepts Chandler Court should have checked Mrs Y for the signs of a stroke earlier in the day on 6 May. The failure to address the risks to Mrs Y properly is a potential breach of the fundamental standards. It is not possible to say whether the outcome would have been any different for Mrs Y if it had checked her sooner. However, the doubt over this is an injustice which requires a remedy. Care UK has already apologised to Mr X for its error. However, it should make a symbolic payment to Mrs Y to remedy the doubt over whether her circumstances could have been different if it had taken action sooner. Care UK said it would take action to ensure Chandler Court learned from its mistake. It needs to confirm what action it has taken to ensure a more cautious approach towards people who have a history of strokes when there is a change in their circumstances.

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Recommended action

13. I recommend Care UK within four weeks:
• Pays Mrs Y £300
• Confirms the action Chandler Court has taken to ensure staff check people for a possible stroke, particularly those with a history of strokes, when there has been a change in their circumstances.
14. Care UK has agreed to do this. It should provide us with evidence it has complied with the above actions.
15. Under the terms of our Memorandum of Understanding and information sharing agreement with CQC, I will send it a copy of my final decision statement.

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Final decision

16. I have completed my investigation on the basis Chandler Court’s actions have caused injustice which requires a remedy.

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Investigator's decision on behalf of the Ombudsman