Summary: We found fault with a nursing home regarding the standard of its record-keeping. This caused Ms Y distress and uncertainty. The nursing home will apologise for this and take action to prevent similar problems occurring in future. The nursing home will also make a symbolic payment in recognition of Ms Y’s distress.

The complaint

1. The complainant, who I will call Ms Y, is complaining about the care provided to her father, Mr X, by The Parks Nursing Home (the nursing home) in 2022. Ms Y complains that:

• the nursing home failed to sit Mr X upright when administering his Percutaneous Endoscopic Gastrostomy (PEG) feed;
• Mr X’s care plans were full of incorrect and inconsistent information;
• Mr X did not receive his medication for two weeks as it was out of stock and the nursing home failed to order more;
• the nursing home failed to change Mr X’s incontinence pads on a regular basis;
• the nursing home failed to administer thickened fluids to Mr X as recommended by the local Speech and Language Therapist (SALT); and
• the nursing home did not support Mr X to engage in any activities during his time in the nursing home.

2. Ms Y said these events were very distressing for Mr X as he was neglected by the nursing home. Furthermore, she says the nursing home’s failure to properly manage Mr X’s PEG feed meant he developed aspiration pneumonia. Ms Y said these events were also very distressing for her.
3. At the point of issuing my draft decision statement, I was of the understanding that Mr X’s placement at the nursing home was part funded by Derby City Council (the Council) and that it therefore shared responsibility for the care provided to him.
4. However, the responses I received to my draft decision statement from the Council and nursing home have clarified that the placement was arranged and funded by the NHS. As a result, the nursing home bears sole responsibility for Mr X’s care and the Council had no role in it. I have therefore amended my findings to reflect this.

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The Ombudsmen’s role and powers

5. 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).
6. 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.
7. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what is more likely to have happened.
8. 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

9. In making my final decision, I considered information provided by Ms Y and discussed the complaint with her. I also considered relevant information from the nursing home, including the care records. I invited comments from all parties on my draft decision statement and considered the responses I receive.

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What I found

Relevant legislation and guidance

Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

10. These Regulations set out the fundamental standards below which care should never fall. The Care Quality Commission (CQC) provides guidance for service providers on how to meet these Regulations.
11. Regulation 17 relates to good governance. The CQC guidance explains that “[r]ecords relating to the care and treatment of each person must be kept and fit for purpose.”
12. The guidance goes on to say that records should be “complete, legible, indelible, accurate and up to date, with no undue delays in adding and filing information, as far as is reasonable.” In addition, records must “[i]nclude an accurate record of all decisions taken in relation to care and treatment and make reference to discussions with people who use the service, their carers and those acting lawfully on their behalf.”

Background

13. In 2022, Mr X was resident in the nursing home. He required extensive care and nursing support. This included management of his PEG feed. This is a tube that is passed directly into the stomach through the abdominal wall. It is most often used for patients who have inadequate oral intake. Mr X received all his food and medication through his PEG feed. However, Mr X could take five teaspoons of thickened fluids five times per day.
14. In August 2022, Mr X suffered a fall and struck his head on his bed. He was admitted to hospital briefly before returning to the nursing home.
15. Mr X was taken to hospital again by ambulance on the evening of 8 October after he became unwell. The clinical team diagnosed him with aspiration pneumonia (a swelling of the lungs which occurs when food or fluid is breathed into the airways instead of being swallowed). Ms Y said clinical staff told her this could have been caused by nursing home staff administering Mr X’s PEG feed incorrectly.
16. Mr X returned to the nursing home on 20 October. The hospital provided revised guidance for Mr Y’s PEG feeding. However, he was admitted again on 24 October as his condition had deteriorated.
17. Mr X did not recover and died in hospital on 28 October.

My analysis and findings

PEG feeding

18. Ms Y complained that staff often administered Mr X’s PEG feed while lying down rather than in a raised position as required by guidelines. Furthermore, she said staff allowed Mr X to lie down immediately after his feed, rather than requiring him to remain in a raised position. She said this led to him developing aspiration pneumonia.
19. The nursing home explained that, at the time of Mr X’s admission, it followed advice from the local Integrated Care Board that required service users to be PEG fed at a 30-degree angle. The protocol also required the service user to remain at this angle for 30 minutes after the feed.
20. The nursing home subsequently received guidance from the local hospital explaining that Mr X should be PEG fed at a 45-degree angle and remain in that position for 45 minutes afterwards. The nursing home said care staff checked on Mr X regularly during the post-feed period.
21. Ms Y said friends of the family had visited Mr X at the care home after his feeds and found him lying flat on his back. She disputed that staff were checking on him at regular intervals and said he was unable to reposition the bed himself as the nursing home claimed. When Mr X was admitted to hospital in October 2022, Ms Y said clinical staff told her Mr X had developed aspiration pneumonia because of being PEG fed in the wrong position.
22. This aspect of Mr X’s care remains a significant area of dispute and the nursing home maintains that care staff followed the appropriate guidelines.
23. I have reviewed Mr X’s nutritional care plan. This clearly recorded that he was known to be at high risk of choking and aspiration. The plan set out that Mr X should be nil by mouth for food but could have sips of thickened fluids. Furthermore, the plan noted the positioning requirements for PEG feeding. This shows care staff were aware of Mr X’s feeding requirements.
24. It is understandable that Ms Y queries how Mr X developed aspiration pneumonia. However, it is important to note that it is not possible to completely remove the risk of aspiration, only reduce it.
25. In the absence of any further independent evidence, I am unable to say, even on balance of probabilities, whether Mr X developed aspiration pneumonia due to the actions of care staff.

Care plans

26. Ms Y said Mr X’s care plans were full of errors and inconsistencies. This included recording his name and history incorrectly, as well as inconsistent information about his care needs and wishes.
27. I have reviewed the care plans relating to Mr X’s time in the care home between July and October 2022. These contain numerous inaccuracies. These include referring to Mr X by several different names and incorrectly recording his life and work history. I am satisfied errors of this kind would have had a limited impact on Mr X’s care. Nevertheless, I accept these will have contributed to Ms Y’s sense that the records were not fit for purpose.
28. However, other errors and inconsistencies were potentially more serious. For example, the care plan records that Mr X both and did not have a diagnosis of diabetes. In other entries (on the same page of the records) it was recorded both that Mr X had capacity to make decisions about his care and that he lacked it.
29. Regulation 17 requires care records to be “complete, legible, indelible, accurate and up to date” and to properly reflect any discussions with service users. The nursing home’s records did not meet the required standards in this area. This was fault by the nursing home.
30. I am satisfied these errors and inconsistencies did not ultimately have a significant impact on Mr X’s overall care. However, they caused Ms Y avoidable distress and uncertainty.
31. In its response to my draft decision statement, the nursing home explained that it identified problems with documentation during an internal quality audit in August 2022 and was working to improve record keeping standards at the time of the events Ms Y is complaining about. I have made a recommendation below to address this issue further.

Medication

32. Ms Y said nursing home staff failed to administer Mr X’s medication as prescribed. She said that, in one case, Mr X ran out of medication and the nursing home did not reorder this for 14 days.
33. This issue was not addressed in its entirety by the nursing home in its complaint responses. However, the nursing home did provide me with relevant information in its response to my enquiries.
34. The nursing home explained that Mr X took various different medications and that these changed throughout the duration of his time there. The nursing home said reordered medication staff that were out stock (or shortly to be out of stock) from the local pharmacy.
35. On 17 August 2002, the care home ordered more of Mr X’s Isosorbide medication. This is a medication used to widen the heart blood vessels to reduce the risk of angina attacks (episodes of chest pain caused by reduced blood flow).
36. The nursing home then chased the prescription again on 2 September.
37. The nursing home administered two doses of the medication on 6 September. The medication was then out of stock and Mr X did not receive a further dose for 14 days.
38. The nursing home made a further request for the medication to the pharmacy on 21 September. This revealed that the GP practice which issued the prescription had ordered a 30mg dose of the medication and the pharmacy was having difficulty sourcing this dosage. The nurse who called the pharmacy asked it to send the medication in 20mg and 10mg doses instead.
39. Mr X began to receive the medication again on 22 September.
40. The evidence I have seen shows there was a delay of 14 days during which Mr X did not receive his Isosorbide medication. However, this was not attributable to fault by the nursing home. Rather, this was due to the pharmacy having difficulty sourcing the correct dose. The care records show the nursing home chased the medication appropriately and made alternative arrangements when the planned dosage was not available.
41. I am satisfied this did not have a significant impact on Mr X’s care. I found no evidence in the care records to suggest Mr X was suffering from angina during this period nor any indication that staff had been required to administer pain relief medication for chest pain.
42. I also note the nursing home has been working with the pharmacy to improve communication and allow for any delays to be identified sooner. This should allow the nursing home to identify alternative arrangements and reduce the likelihood of similar problems occurring in future.

Continence care

43. Ms Y said nursing home staff failed to change Mr X’s incontinence pads regularly and left him without a urine bottle or a call buzzer to call for assistance. On one occasion, Ms Y said Mr X had soiled himself and that his room smelled so bad that she had to ask for a change of room.
44. In its responses, the nursing home explained that, on his arrival in July 2022, staff would support Mr X to use the toilet or a urinal bottle. However, as Mr X could sometimes be incontinent, the nursing home also supplied incontinence pads for his use. The nursing home said there were times when Mr X relied more upon incontinence products.
45. The nursing home went on to say that staff changed Mr X’s continence pads regularly and that his skin remained intact. The nursing home explained there may be times when a visitor arrives between checks and that an episode of incontinence may occur before a member of staff has been able to address it.
46. Mr X’s care plan recorded that he could experience episodes of incontinence both at night and during the day. This placed him at high risk of developing skin damage such as moisture lesions (sores caused by prolonged exposure to wetness). The care plan noted that Mr X could sometimes tell when he needed the toilet but would also need prompting and encouragement from care staff.
47. The daily care records show that care staff were checking Mr X regularly and changing his incontinence pads where necessary. They also helped Mr X to the toilet where possible. Furthermore, the care records suggest that Mr X’s skin remained intact. This suggests effective continence care.
48. I identified one occasion on which Mr X was found to be wet and there was a wet patch on the floor of his room. A care worker noted that Mr X had a red mark on his bottom. The care worker gave Mr X a bed bath and changed his bedding. She noted he was then “settled and asleep”.
49. On another occasion, Mr X was noted to have experienced an episode of incontinence and care staff did not change the wet pad for 45 minutes.
50. Nevertheless, these appear to have been isolated episodes and the nursing home acknowledged and apologised for them. I accept it will have been distressing for Ms Y to find out about these incidents. However, I consider the nursing home’s response to be appropriate.
51. I also accept the nursing home’s point that there will be occasions where a friend or relative visits a resident and finds they have suffered an episode of incontinence which care staff have not yet been able to deal with. This will be unavoidable at times, even with appropriately regular checks.
52. Overall, the care records support the nursing home’s view that it provided Mr X with appropriate continence care. I found no fault on this point.

Fluids

53. Ms Y said a SALT had reviewed Mr X and recommended he be given five teaspoons of thickened fluid per day. However, Ms Y said nursing home staff almost never gave Mr X the thickened fluids.
54. The care records show that, in July 2022, a SALT recommended Mr X be given five teaspoons of mildly thick fluids per day. This is a fluid that has been thickened to make the fluid move slightly slower than an unthickened fluid. This was a trial to test Mr X’s swallowing ability. It was not intended to form part of Mr X’s fluid intake, which was managed through his PEG. The SALT recommended that Mr X should have no other oral intake and should receive his food through his PEG.
55. In its complaint responses, the nursing home recognised Mr X was to be offered thickened fluids. It said Mr X often declined oral fluids as he was concerned about the risk of aspiration. However, the nursing home acknowledged the fluid charts contained omissions and that it could not therefore prove that Mr X was offered five teaspoons of fluid per day.
56. I have reviewed the records in questions and note many omissions in relation to the administration of oral fluids for Mr X. If Mr X was indeed refusing oral fluids, nursing home staff made few entries in the records to reflect this. Furthermore, I found no evidence discussion with Mr X regarding his concerns about aspiration.
57. As above, this is evidence of poor record keeping. This was not in keeping with the Regulations and represented fault by the nursing home.
58. This resulted in uncertainty for Ms Y who cannot now be assured that Mr X was offered oral fluids as regularly as he should have been.

Activities

59. Ms Y said she asked nursing home staff to support Mr X to join in with activities. However, she said this did not happen and that staff simply noted that Mr X was asleep or had refused to join in.
60. In its complaint response, the nursing home said Mr X largely chose to remain in his room and declined to take part in activities. However, the nursing home accepted the records did not always reflect the efforts care staff made to encourage Mr X to participate.
61. Mr X’s care plan recorded that he liked to socialise and talk to care staff. The care plan also noted that staff would support Mr X to engage in any activities that interested him.
62. The care records show that Mr X largely chose to remain in his room during his time in the nursing home. At times, he remained in bed and on other occasions he sat out in his chair. He was also noted to enjoy watching television.
63. However, I found very few entries to suggest care staff were actively encouraging Mr X to socialise or engage in activities. Similarly, there is little by way of recorded social interaction between care staff and Mr X, though the nursing home told me Mr X regularly conversed with staff.
64. It is important to be clear that Mr X was considered to have capacity to make decisions about his day-to-day care. This meant that he was entitled to remain in his room or decline to take part in activities if he wished to.
65. Nevertheless, the absence of any detailed records in this area mean Ms Y cannot now be assured about the level of engagement between staff and Mr X. Again, the care records in this area are not in keeping with the Regulations. This was fault by the nursing home.
66. This caused further uncertainty for Ms Y.

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Agreed actions

67. Within one month of my final decision, the nursing home will:

• write a letter to Ms Y apologising for the distress and uncertainty caused to her by the nursing home’s failure to keep records to the standard required by Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014;
• pay Ms Y £300 in recognition of this; and
• explain what action it has taken to date, or will take, to ensure the nursing home has appropriate guidance in place for care staff on maintaining “complete, legible, indelible, accurate and up to date” records in keeping with the Regulations.

68. The nursing home will provide us with evidence it has complied with the above actions.

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Final decision

69. I found fault by the nursing home with regards to the standard of the record keeping in this case.
70. I am satisfied the actions the nursing home will now take represent a proportionate remedy for the injustice caused to Ms Y by this fault.
71. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman