Summary: Mrs X complains Kiwi House Care Home failed to look after her mother-in-law (Mrs Y) properly, resulting in her mobility declining. Kiwi House was not responsible for the decline in Mrs Y’s mobility. Nevertheless, it needs to apologise for failings in its record keeping and take action to improve it.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains Kiwi House Care Home (Kiwi House) failed to look after her mother-in-law properly, resulting in her mobility declining.

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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)
3. This complaint involves events that occurred during the COVID-19 pandemic. The Government introduced a range of new and frequently updated rules and guidance during this time. We can consider whether the care provider followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”.

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How I considered this complaint

4. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the documents the care provider has provided;
• considered the Ombudsman’s guidance on remedies; and
• shared a draft of this statement with Mrs X and the care provider, and taken account of the comments received.

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What I found

Key facts

5. Mrs X’s mother-in-law, Mrs Y, has dementia. She went to stay in Kiwi House on 2 March 2021 for respite care. This followed a sudden decline in her condition, which meant it was not safe for her to remain at home.
6. Kiwi House kept records of the care provided for Mrs Y. I refer to the key contents below.
7. According to the records, on 2 March Mrs Y tested negative for COVID-19 after a lateral flow test. She moved around independently. Although she should have isolated in her room, until a further test for COVID-19, she would not do so.
8. Mrs X says on 3 March staff at Kiwi House told her the lateral flow test had been inconclusive. She says they told her they did not offer lateral flow tests to new dementia residents, but later in March the Manager told her this was not correct.
9. Mrs Y remained mobile. She was often unsettled at night, staying up late. In the evening of 4 March she fell on her bottom in the lounge. She had no apparent injuries but Kiwi House noted the need to monitor her. It told Mr X about the fall.
10. Mr X visited his mother on 6 March.
11. Mr & Mrs X went to see Mrs Y on 7 March. Mrs X says she was in a wheelchair on this and every other visit she made. She says they raised concerns about her swollen legs and asked if a GP had seen her about them. Kiwi House’s records do not mention using a wheelchair. They say: staff aided Mrs Y with mobility in the morning; she had a very tight bandage on her knee for support which was taken off for a while; and she got herself to bed with little or no support.
12. Kiwi House says it arranged for an advanced nurse practitioner to see Mrs Y as she had swollen legs. But this is not reflected in its records.
13. On 8 March Mrs Y needed a little help when assisted to the lounge.
14. On 9 March two nurses visited to get Mrs Y’s views on her future care. She said she was happy to stay at Kiwi House. She walked around chatting to people. Later in the evening she wandered around until staff settled her back in her room.
15. On 10 March Mrs Y asked to go back to bed after receiving personal care in the morning but got up again for lunch. Family visited in the afternoon.
16. On 11 March Mrs Y did not want to shower in the morning as she was “in pain with her knee”. A district nurse visited because of her swollen legs and advised keeping them raised. Kiwi House spoke to Physiotherapy and discussed the benefits of Mrs Y using a walking frame. Kiwi House suggested this was not necessary as she could walk independently. Physiotherapy agreed to provide a walking stick on 15 March, because of the pain in her knee. Mrs Y received a negative test result for COVID-19.
17. On 13 March Mrs Y had a phone call with a relative.
18. On 14 March Mrs Y received “help with walking” in the evening but could walk independently when she returned to her room.
19. In the early hours of 16 March Mrs Y was pacing the corridors and did not want to go to bed. She went to bed around 01.30.
20. On 17 March Mrs Y spoke to a relative over the telephone. Kiwi House received a call to check how she was doing with her walking stick. Kiwi House said it was not aware she had one and suggested calling back in the morning.
21. Mrs Y did not go to bed until around 03.00 on 18 March, after wandering round, entering other residents’ rooms and trying to find the right door to go home.
22. On 19 March Mrs Y’s legs were raised at 00.05. This is the only reference to staff checking her legs were raised until 23 April. Mrs Y did not stay in bed but got up and sat in the lounge, returned to bed around 01.00 and slept from 02.00. She moved around independently.
23. On 21 March Mr X visited his mother. Staff helped with mobility when she went to her room to go to bed. Mrs X emailed Kiwi House asking it to arrange a GP visit.
24. On 22 March Mrs Y was confused and kept wandering out of her room during the early hours. Staff helped her transfer to the lounge. Kiwi House spoke to a GP about her swollen legs. The GP asked for blood and urine samples.
25. Mrs Y was unsettled again on 23 March. Mr X visited his mother. She was “struggling with her right leg” so was added to the GP list.
26. On 24 March Mrs Y had a settled night. A nurse took a blood sample.
27. Mrs Y went to bed around 01.00 on 25 March. She was very unsteady on her legs and needed help walking in the morning and used a walking stick. She said her right knee was painful. A GP prescribed pain killers and a laxative.
28. Mrs Y was awake all night on 26 March and refused to go to bed. Mr X visited.
29. At 08.43 on 27 March Kiwi Houses recorded replacing Mrs Y’s dentures. Its records say “Teeth cleaned and/or mouth wash” at 17.36. She later had supper in the dining room (“offered two sandwiches and some crisps”).
30. On 28 March Mrs Y was up and down during the night. In the morning her dentures were missing (last mentioned at 08.43 on 27 March). Mrs X visited. She said she was not happy that Mrs Y’s teeth were missing. She also asked what Kiwi House was doing about her leg, as she was struggling and it was weeping. Kiwi House said it would contact the district nurses (which it did later that day to request a visit). It told Mrs X Mrs Y had had a few unsettled nights and agreed to monitor her. Kiwi House called Mr X about Mrs Y’s missing false teeth and told him they would look for them. Mrs Y managed to eat all her food. She did not use her walking stick. Kiwi House told Mr X about a district nurse visiting to dress Mrs Y’s leg and saying to monitor it. Mrs Y said both knees were painful.
31. On 29 March Mrs Y was awake most of the night.
32. Mrs Y slept most of the night on 30 March. A district nurse visited to replace the dressing on her leg, and said it was looking better. Her dentures remained missing.
33. On 31 March Mrs Y’s dentures were “replaced” at 09.01. Mr X visited.
34. On 1 April Mrs Y went to bed at 03.17. She moved independently.
35. On 2 April Kiwi House spoke to a GP who noted Mrs Y had low vitamin B. A GP visited later who prescribed medication to reduce the fluid in her legs. The GP said to refer Mrs Y to physiotherapy and suggested speaking to her family about getting vitamin D tablets. Kiwi House told Mr X about the GP’s advice.
36. Mrs Y was unsettled in the evenings of 3 and 4 April.
37. Mr X visited on 6 April. Mrs Y had her second COVID-19 vaccination (Astra-Zeneca) having had the first (Pfizer) before she went to Kiwi House.
38. Between 08.06 and 13.59 on 7 April Mrs Y’s glasses were mislaid. By 14.50 they had been found. A GP saw Mrs Y and decided to refer her for a heart scan. The GP increased the dose of the medication for water retention. Kiwi House called Mr X to update him.
39. Mr X visited on 8 April. Mrs Y remained mobile.
40. On 11 April Mrs Y had an unwitnessed fall. Staff found her sat on the floor in her bedroom around 22.30. She had no apparent injuries, did not complain of pain and could stand up with help. Staff helped her into bed.
41. Around 05.30 on 12 April Mrs Y’s right knee was in pain so she took a painkiller and used a wheelchair in the morning. Kiwi House noted the need to refer her to a GP if her mobility did not improve. By early afternoon she was “happy walking around” but by mid-afternoon she was not walking and using a wheelchair again. Family visited in the afternoon.
42. On 13 April Mrs Y was unsteady on her feet and needed a lot of help. A GP visited who took Mrs Y off the medication for water retention and said a district nurse would have to dress the leg. Kiwi House’s record of the visit refers vaguely to other medication but does not say what it was. Later records suggest it was antibiotics.
43. Mrs Y had a family visit in the afternoon of 14 April. She remained unsteady on her feet although another record says she had “been happy walking around”.
44. On 15 April Mrs Y remained very unsteady on her feet and said her legs hurt. She was advised to sit and rest but kept trying to walk around. Mrs Y declined her lunch but ate her evening meal.
45. Kiwi House updated Mrs Y’s risk assessment and care plans. They said she was at high risk of falls. The mobility assessment said:
• Mrs Y had swollen legs which caused pain and also had pain in her knees, for which she had medication;
• she had good days, on which she could stand and walk short distances with a stick and support from one person, and bad days when she needed a wheelchair;
• she had had one fall at Kiwi House, although she had had two falls;
• a sensor was in place to alert staff when she moved around without staff support;
• staff encouraged Mrs Y to rest her legs but because of short-term memory loss she often forgot this advice and would stand to walk unaided.
46. A district nurse visited on 16 April. Kiwi House’s record of the visit is poorly written so difficult to understand, but it refers to a full leg dressing and the nurse returning the following week.
47. On 17 April Mrs Y did not engage in communal social activities.
48. On 18 April Mrs Y did not want to attend communal social activities in the morning but did so in the afternoon. Mr X visited her in the afternoon. Mrs Y was unsettled on and off and very unsteady on her feet.
49. On 19 April Mrs Y went for a walk in the grounds of Kiwi House. She remained unsettled and at times agitated. Staff tried to encourage her to rest.
50. Mrs Y was more settled on 20 April and took part in communal social activities.
51. On 21 April Mrs Y had an unwitnessed fall and was found lying on her back in her room around 07.00. She had no apparent injuries. Kiwi House updated Mr X.
52. On 22 April Mrs Y used a wheelchair for part of the day. But she was pacing up and down in the afternoon. She was unsettled and reassured when she became agitated.
53. On 23 April Mrs Y had an unsettled night. She removed the dressing from her leg. She was pacing up and down. Staff encouraged her to sit with her legs raised but she did not want to sit down, so staff encouraged her to use her stick.
54. Mrs Y remained unsettled on 24 April, walking around with staff reminding her to use her walking stick.
55. Mrs Y was a little more settled on 25 April. Kiwi House contacted a district nurse as the wound on her leg was “leaking”. The district nurse said to put a dressing on and a nurse would visit the next day.
56. Mrs Y moved to another care home on 26 April.
57. When Kiwi House responded to Mrs X’s complaint in June, it said:
• as required, it had tested Mrs Y for COVID-19 five days after she moved to Kiwi House (7 March);
• on the same day, Kiwi House identified swollen legs and consulted an advanced nurse practitioner (and sought further advice from medical professionals on many other dates);
• all mislaid possessions had been found and were taken away when Mrs Y left Kiwi House;
• a medical professional had made the decision to give Mrs Y a different COVID-19 vaccine for her second dose; and
• it apologised for the negative experience Mrs Y had at Kiwi House.
58. When the Care Quality Commission (CQC) inspected Kiwi House in April 2021, it found it was inadequate overall, including in being safe and well-led. It found it needed to make improvements to be effective, but was good at caring and being responsive. By August 2021 it was no longer inadequate, but required improvement to make it safe, effective and well-led. It remained good at being caring and responsive.

Did the care provider’s actions cause injustice?

59. 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. Under regulation 17 care provider are required to keep accurate, complete and contemporaneous records of the care provided.
60. There are gaps in Kiwi House’s records and some of them are poorly written (see paragraphs 42 and 46 above). There is nothing to explain why Mrs Y was using a wheelchair when Mr & Mrs X visited on 7 March. It should not have been necessary for Mrs Y’s family to raise concerns about her condition on 7 and 28 March before Kiwi House took action and sought to involve the district nurses. On 11 March a district nurse advised keeping Mrs Y’s legs raised because they were swollen. The only references to staff checking on this was on 19 March and 23 April.
61. While these were faults, it is not possible to say what injustice they may have caused. There is no dispute over the fact Mrs Y’s mobility declined while she was at Kiwi House. But it does not necessarily follow from this that poor care by Kiwi House was responsible for the decline. It is clear from the records that Mrs Y liked to move around, both during the day and at night. Kiwi House could not prevent this. Because of her memory problems, Mrs Y found it difficult to follow advice and did not always use her stick. The records show Kiwi House took action to reduce the risk of falls (for instance putting a sensor in her room), but that did not mean it could prevent her from falling.
62. Nevertheless, Kiwi House needs to apologise for the failings in its record keeping and the fact that at times it needed prompting to refer Mrs Y for medical attention, and the distress this caused. It also needs to take action to improve its records keeping.

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Recommended action

63. I recommended Kiwi House:
• within four weeks writes to Mr & Mrs X apologising for distress caused by the failings in its record keeping and the fact that at times it needed prompting to refer Mrs Y for medical attention; and
• within eight weeks takes action to improve its record keeping and provides evidence it has done this.

Kiwi House has agreed to do this.

64. Under the terms of our Memorandum of Understanding and information sharing protocol with the CQC, I will send it a copy of my final decision statement.

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Final decision

65. I have completed my investigation on the basis that Kiwi House will apologise to Mr & Mrs X for the injustice caused to them and improve its record keeping to prevent future injustice to others.

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Investigator's decision on behalf of the Ombudsman