Summary: Mr X complained about the quality of care, the Council’s commissioned care provider, Bartholemew lodge nursing home Ltd, provided to his mother Mrs Z. We find the Council was at fault. This caused significant distress to Mrs Z and Mr X. To address this injustice caused by fault, the Council has agreed to apologise, make a symbolic payment and remind staff of the relevant guidance.

The complaint

1. The complainant, Mr X, complains about the quality of care, the Council’s commissioned care provider, Bartholemew lodge nursing home Ltd, provided to his mother Mrs Z. He said:
• the home failed to provide Mrs Z with enough water;
• the home only showered Mrs Z once a week;
• Mrs Z was found half naked in bed with no sheets;
• Mrs Z’s room door was often closed;
• the home failed to do Mrs Z’s laundry regularly;
• the home lost Mrs Z’s dentures; and
• the call bell was either disconnected or out of Mrs Z’s reach.
2. Mr X said because of this Mrs Z did not receive the correct care. He said this has caused him significant distress.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this report, we have used the word ‘fault’ to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. We refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
5. We normally name care homes and other care providers in our reports. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
6. When considering complaints, we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
8. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

9. I spoke with Mr X about his complaint. I considered all the information provided by Mr X and the Council.
10. Mr X and the Council now have an opportunity to comment on my draft decision. I will consider their comments before making a final decision.

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What I found

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 sets 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.
12. Regulation 9 says the care and treatment of service users must be appropriate, meet their needs and reflect their preferences.
13. Regulation 10 says care providers must treat all service users with dignity and respect.
14. Regulation 14 says care providers must make sure that people have enough to eat and drink to meet their nutrition and hydration needs.
15. Regulation 17 says care providers should “maintain securely” records and should have “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”.

Summary of the key events

16. Mrs Z was admitted to the nursing home on 2 February 2023. The care plan stated she was high risk of having constipation. Staff were to encourage her to drink fluids daily to reduce the risk.
17. A risk assessment stated:
• Mrs Z occasionally pulls her call bell out, rolls it up and either puts it in her bag or on the table;
• Mrs Z needed assistance with washing and dressing; and
• staff were to check and empty her stoma bag and catheter as and when needed.
18. A daily living assessment stated:
• staff were to ensure the call bell was reachable for Mrs Z; and
• staff were to ensure pressure relief was provided every 3-4 hours.
19. Following reports of concern from Mr X, the Council’s deprivation of liberty (DOLS) team visited Mrs Z at the home in March 2023. It was noted that:
• on the officer’s visit, the call bell was not accessible for Mrs Z;
• Mr X had raised concerns about Mrs Z not being able to access the call bell as she had used her mobile phone once to call him;
• the nursing homes manager had put up a sign in Mrs Z’s room to remind staff not to disconnect the call bell;
• Mrs Z sometimes puts the call bell in her bag. But said staff will frequently check the buzzer is in reach; and
• Mr X was concerned about the level of care provided to Mrs Z as he said she had not had a shower since admission.
20. In the same month the Council’s safeguarding team raised Mr X’s concerns to its DOLS team. Mr X said he had raised these concerns directly with the home but said the issues are not always rectified. It was noted that:
• on 20 February 2023, Mrs Z was lying half naked in the bed, the door was shut and she had no duvet cover on;
• the door has an automatic clip on it to keep it open. But this had been broken for several weeks. Mr X said he had been asking for it to be fixed;
• concerns as Mrs Z had not had a shower for a period of time;
• Mrs Z kept getting urine infections;
• the nursing home did not always have medication on time. On one occasion Mr Z had to go and collect the tablets from a chemist so Mrs Z could have them on time; and
• the call bell was rolled up and put in a drawer. Mr X does not think Mrs Z did this as he said she struggles to get out of bed.
21. In response to the concerns raised the nursing home said:
• it apologised for the incident when Mrs Z was left half naked in bed with no covers. They said Mr X found her and informed staff who instantly attended to her;
• the door had now been fixed but said it only required new batteries. It said there was no previous entry in the maintenance book regarding this problem;
• it had informed Mr X that Mrs Z was on weekly showers every Friday. It said residents shower or bath preferences are documented on admission. Mrs Z informed staff a weekly shower was adequate for her. It said it asked Mr X to ask Mrs Z if she wanted to have showers more frequently;
• the GP has been prescribing courses of antibiotics to Mrs Z to treat her urine infection;
• the chemist makes deliveries every morning. Mr X offered to fetch the medication on one occasion;
• on one occasion Mr X did a medication review with the GP on the phone and brought the new medication prescribed. But at that point the surgery had not informed staff;
• it had advised Mr X to tell staff if the call bell was not in reach. A note was also put in Mrs Z’s room to emphasise this to staff; and
• it had informed Mr X of incidents where Mrs Z had rolled the call bell up and put it in her bag or on the table.
22. The ambulance service was called out to Mrs Z on 27 March 2023. It was noted that nursing staff were to ensure they kept encouraging Mrs Z to drink.
23. Mrs Z was admitted to hospital the following day. Mr X said Mrs Z was severely dehydrated. Mrs Z sadly died on the 3 April 2023.

The fluid intake records and hourly checks records

24. The first two weeks of Mrs Z’s stay at the nursing home, she was offered drinks consistently every hour. It was noted Mrs Z refused fluids on three occasions during this period.
25. On the 15 February 2023, there is a gap in the fluid chart between 1pm and 9pm. There is also a gap on the hourly checks record between 3pm and 8pm.
26. On the 26 February 2023 there is an entry at 7am stating Mrs Z had a drink. But then there is a gap until 9pm. There is also a gap on the hourly checks record between 7am and 7pm. There is a gap on the 28 February between 8am and 9pm. The hourly checks state Mrs Z was given drinks at 11am and 4pm.
27. On the 1 March 2023, there are entries every hour up until 11am. But there is a further gap until 9pm. The hourly checks stated Mrs Z had drinks at 1pm, 3pm and 5pm.
28. The week commencing 6 and 13 March 2023, the records state Mrs Z was offered and accepted drinks every hour.
29. The following week, Mrs Z was offered and accepted drinks throughout the day. But there was a two-hour gap between offers on some occasions. Mrs Z did sometimes refuse. But Mrs Z was having around 950ml to 1500ml of fluids per day. This deteriorated towards the end of the week and the home contacted the GP.
30. The week commencing 27 March 2023, Mrs Z was offered drinks throughout the day. But it was noted she sometimes refused. There are no entries noted on the 28 March.

The food intake records and hourly checks records

31. The first five weeks of Mrs Z’s stay, she had three meals per day plus snacks. It was noted during that time she declined snacks on two occasions. But on the 26 February 2023, there are no entries noted. There is also a gap on the hourly checks record between 7am and 8pm.
32. The week commencing the 6 March 2023 between Wednesday and Sunday, Mrs Z had three meals per day plus snacks. But on the Monday, there are no entries. The hourly checks stated Mrs Z had breakfast and snacks in the morning. There was a gap between 12 and 8pm. On the Tuesday it was noted Mrs Z refused breakfast and lunch. No further entries were noted. The hourly records stated in the evening Mrs Z didn’t eat much.
33. On the 19 March 2023, Mrs Z was asleep in the morning. But there are no further entries noted. The hourly records state Mrs Z had breakfast and declined a snack. There was a gap in the records between 11am and 8pm.
34. The following weeks, it was noted Mrs Z often refused meals.

The daily care records and GP records

35. The care records note two entries per day. One early morning and one in the afternoon.
36. The notes state Mrs Z was often made comfortable.
37. During Mrs Z’s 54 day stay, the notes state she was assisted with washing daily. She was assisted to have a shower on the 15 October and 2 March.
38. At the start of Mrs Z’s stay the nursing home spoke with the GP about Mrs Z’s delirium. The GP prescribed antibiotics. This was later prescribed again for a urine infection.
39. The notes state Mrs Z removed her catheter a couple of times. Staff explained the risks to Mrs Z and Mr X.
40. In March 2023 the notes would sometimes specify that the call bell had been placed within Mrs Z’s reach.
41. Towards the end of March 2023, it was noted Mrs Z was not eating or drinking much. Staff encouraged her to drink. Staff raised this with the GP who recommended a blood test. The GP prescribed sertraline and it was noted if Mrs Z continued to refuse food and fluids, there was a plan for supplements to be taken.
42. On 27 March 2023, it was noted Mrs Z was alert in the afternoon and drinking with a straw.
43. On 28 March 2023 Mrs Z continued to decline food and fluids.

Complaint to the nursing home

44. Mr X complained to the nursing home. In summary he said:
• his mother was rushed to hospital on 28 March 2023;
• her symptoms were, severe dehydration and malnutrition, hyper delirium due to an ongoing water infection and severely low blood pressure;
• after various tests it was confirmed, the infection had spread to Mrs Z’s blood;
• the nursing home had left his mother alone and had not monitored her water intake;
• the nurse who attended the nursing home reported serious concerns for the welfare of Mrs Z on 28 March 2023. They stated Mrs Z could not return to the nursing home;
• after raising the issue about the call bell, Mrs Z’s bed was moved further away from the wall away from the call bell;
• the door to Mrs Z’s bedroom would not stay open for weeks;
• he founds his mother in her room with the door shut, she was half naked with no duvet cover;
• staff used a bucket for his mother’s dirty clothes which was left in the room all week until full. He said at that point, Mrs Z had no other clothes to wear;
• Mrs Z wanted more showers, but this was never increased; and
• after the home received the safeguarding concerns, staff lost Mrs Z’s dentures and were never found. He said Mrs Z was unable to speak properly for the last two weeks of her life.

Nursing homes response

45. In response the nursing home said:

• throughout Mrs Z’s stay the GP prescribed three courses of antibiotics. The first course was due to staff insisting to the GP there appeared to be a delirium overlay from hospital discharge. Second and third courses were due to a urine infection;
• the nursing home has full records of Mrs Z’s fluid and food intake;
• staff alerted the GP to Mrs Z refusing food and fluids and having a lower mood on 17 March 2023. The GP requested bloods be taken, prescribed sertraline and put in place supplements should her food and fluid intake deteriorate further;
• blood results received on 19 March 2023 confirming no infection;
• over the last three days at the home, Mr X tried to encourage and assist Mrs Z to eat and drink. But said Mrs Z remained refusing;
• staff requested the GP for a visit on 27 March 2023. The GP stated they would complete a telephone consultation the next day. Staff were not happy with this arrangement and contacted the community matron to visit;
• the visit took place on 27 March 2023. The nurse took observations which had diminished from the observations taken earlier. Paramedics arrived and Mrs Z’s observations improved;
• it was agreed there would be a follow up visit the next day. It was noted Mrs Z’s blood sugar reading could not be noted due to being low. The nurse at the nursing home rang 999 and Mrs Z was taken to hospital;
• following Mr X’s concerns raised, a meeting took place with the manager on 8 March where all areas were discussed, and actions taken. It said no further concerns were raised by Mr X after this;
• when Mrs Z’s dentures went missing on 20 March 2023, the dentist was contacted immediately. But an appointment did not take place before Mrs Z went into hospital. It apologised.

Analysis- was there fault by the Council causing injustice?

46. The care plan stated Mrs Z was to be encouraged to drink one and a half to two litres of fluids daily. When Mrs Z was offered drinks hourly, this was usually 100-200mls at a time. During Mrs Z’s stay, her average fluid intake was 1349 ml per day.
47. But the notes were not always consistent. There are large gaps on some days on both the fluid and hourly checks records, where there are no entries. This is fault and not in line with regulation 17. I note the nursing home did contact the GP in March 2023 as Mrs Z was not eating or drinking. But the missing entries were in February and the start of March. This caused uncertainty and distress to Mr X.
48. As detailed in paragraphs 31 and 32, there was also missing entries within the food records. This is fault and not in line with regulation 17. As per paragraph 32, I note the hourly checks did state Mrs Z was given breakfast and snacks. But there was a further gap in the records. This caused further uncertainty and distress to Mr X.
49. Towards the end of Mrs Z’s stay at the home, the fluid records were more consistent. On 27 March it was noted that Mrs Z was refusing drinks. Staff contacted the GP who arranged a blood test. The plan was for Mrs Z to take supplements if she continued to refuse fluids. I cannot criticise this.
50. Ambulance staff had been out to Mrs Z on 27 March 2023. They advised staff to encourage her with fluids. It was agreed the community matron would attend the next day for a follow up visit.
51. On the 28 March 2023 the notes stated Mrs Z was settled in the morning and there had been regular checks. Mrs Z was checked again by staff and physical observations were taken. The community matron attended as agreed and they raised concerns for Mrs Z. The nursing home called an ambulance and Mrs Z was taken into hospital.
52. Mr X said Mrs Z’s fingers had turned purple by the time she was taken to hospital. He said if staff were keeping an eye on Mrs Z throughout the night as instructed to do so by paramedics, then the nursing home would have recognised this sooner. But from the evidence seen, the nursing home had monitored Mrs Z and had taken physical observations shortly before the community matron attended. Therefore, we could not criticise this.
53. The nursing home stated on admission, Mrs Z requested one shower per week. We asked to see evidence of this. But other than the managers email stating this was what had been agreed, there is no evidence in the assessment to support this. The assessment notes Mrs Z needed assistance to wash.
54. But if Mrs Z did state her preference was for one shower per week, the records do not evidence this was provided. It was recorded that Mrs Z had a shower twice during her 54 day stay. This is fault and not in line with regulation 9 and 17. The notes did state Mrs Z was assisted with a wash daily.
55. There is evidence of further fault. The assessment completed on the 4 February 2023 stated staff were to ensure pressure relief was provided every 3-4 hours. The nursing homes notes include two entries, one early morning and one in the afternoon. There is a lack of evidence to support that pressure relief was provided as per the assessment. This is not in line with regulation 17. Based on incomplete record keeping, on the balance of probabilities it is likely that Mrs Z did not always get the care she needed. This caused significant distress to Mrs Z and Mr X.
56. Mr X raised concerns about Mrs Z being left in her room with the door closed. He said she was half naked in bed with no sheets. This is fault. We note the staff did attend to Mrs Z immediately after Mr X reported it, but this has caused significant distress to Mrs Z and Mr X. This is not in line with regulation 10.
57. Mr X said Mrs Z would often run out of clothes as the nursing home allowed her laundry to build up. Mr X said this issue was resolved after the DOLS team raised it with the nursing home. The Council told us laundry is undertaken daily. But it said it has no supporting evidence as its not documented.
58. As laundry is undertaken daily, we would have expected Mrs Z’s laundry to have been done more regular. Mr X said Mrs Z would sometimes have to wear other resident’s clothes. But the nursing home said this was never reported to the home. We have two differing accounts of what happened, and I cannot take a view on this. But I recognise this issue was resolved when the DOLS team raised it.
59. Mr X said Mrs Z’s room door was often closed. This was also resolved after the DOLS team raised it. The nursing home said the batteries needed replacing. It said it had no record of this being raised sooner. But Mr X said he had raised it. We have two differing accounts of what happened, and I cannot take a view on this. But we acknowledge the nursing home did take action.
60. Mrs Z’s dentures went missing on 20 March 2023. This is fault and not in line with regulation 10. We recognise the nursing home did contact the dentist to arrange an appointment and apologised. But Mr X said Mrs Z spent the last two weeks of her life unable to speak properly. This caused Mrs Z and Mr X significant distress.
61. An assessment stated staff were to ensure the call bell was reachable for Mrs Z. It was also noted Mrs Z sometimes rolled the call bell up and put it on the table or in her bag. Mr X raised concerns about the call bell being unreachable for Mrs Z. When the DOLS assessor visited in February, they also found the call bell to be unreachable for Mrs Z. On the balance of probabilities, it is likely that the call bell was not always reachable for Mrs Z. This is fault.
62. In response the nursing home put a sign up to ensure staff were leaving the call bell out for Mrs Z. But Mr X said the issue did continue. He said call bell was moved behind the bed and Mrs Z’s bed was moved away from the wall. But the nursing home disputes this. In March 2023 the notes would sometimes specify that the call bell had been left in reach. The nursing home did also check on Mrs Z every hour. But there are seven non-consecutive days where the hourly checks are not consistent. Therefore, it is not possible to know how often the call bell was left reachable. This caused uncertainty to Mr X.
63. We acknowledge the nursing home has implemented an action plan to reduce the risk of similar incidents. This includes:
• updating the hourly check with adding call bell check in the documentation;
• reiterate the importance of nurses checking the food and fluid chart a couple of times during the day to ensure it is filled in properly;
• allocated a staff member to monitor the documentation and ensure that the service uses are getting enough food and fluids;
• ensuring the care plan is more robust and person centred to capture the personal hygiene information according to the service users wish. E.g. frequency of showers; and thorough audit on the care plan to capture the deterioration of the service user and update the plan accordingly.

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Agreed action

64. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the Care Provider, I have made recommendations to the Council.
65. Sadly, it is no longer possible to remedy the injustice to Mrs Z as she has died. To remedy the injustice to Mr X caused by fault, within one month of the date of my final decision the Council has agreed to:
• write to Mr X with an apology that takes account of our published guidance on remedies and accepts the findings of this investigation; and
• pay Mr X £300 to acknowledge the distress caused to him by the fault identified in this statement.
66. Within two months, issue written reminders to the care provider to ensure they are aware of Regulation 9, 10, 14 and 17 of the CQC guidance on how to meet the fundamental standards.
67. The Council should provide us with evidence it has complied with the above actions.

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Final decision

68. I have completed my investigation with a finding of fault causing injustice for the reasons explained in this statement. The above agreed actions provide a suitable remedy for the injustice caused by fault.

Investigator’s final decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman