Summary: Mr X complains about the way the Care Provider dealt with the late Mr Y when he was seriously unwell and the way it handled his complaint about this. The Ombudsman finds the Care Provider caused injustice when it failed to keep accurate records and check on Mr Y appropriately. Also, in the way it handled Mr X’s complaint. The Care Provider has accepted this and will ensure staff receive further training in record keeping. It has agreed to apologise and refund the fees for Mr Y’s last day.

The complaint

1. The complainant, whom I shall refer to as Mr X, complains that when his late father, Mr Y, went to Ashridge Court Care Centre after an operation, the Care Provider:
• failed to check Mr Y, for two hours although he was short of breath and had stomach pain;
• Handled Mr X’s complaint about this poorly; and
• Did not keep adequate records.
2. Mr X says he was also disappointed with the quality of the food and Mr Y expected better from the service for which he paid £1,100 per week. He says Mr Y was left alone in pain at the time he most needed support and avoiding this was the reason he moved to the home. Mr X says the Care Provider should refund all fees paid and waive outstanding amounts. He would also like an apology and changes to its practice.

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The Ombudsman’s role and powers

3. 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. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. If we are satisfied with a care provider’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)
6. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended). Mr X is Mr Y’s son and we consider him a suitable person to bring this complaint on Mr Y’s behalf.

7. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

8. I considered information from the Complainant and from the Council.
9. I sent both parties a copy of my draft decision for comment and took account of the comments I received in response.

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What I found

Background

The Care Quality Commission

10. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
11. Regulation 16 is about complaints. The guidance says “Any complaint received must be investigated and necessary and proportionate action must be taken in response to any failure identified by the complaint or investigation”. Also, that “complainants must not be discriminated against or victimised. In particular, people's care and treatment must not be affected if they make a complaint, or if somebody complains on their behalf”.
12. Regulation 17 is about good governance. 17(2)(c) says care providers should “maintain securely 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”.

What happened

13. Mr Y had a life limiting health condition and went to Ashridge Court Care Centre (Ashridge CCC) for respite following an operation at the end of February 2019. Mr X said Mr Y paid for a more expensive care home as he wanted to be looked after well. Ashridge CCC is run by Ashridge Court Limited (the Care Provider).
14. About two weeks after Mr Y was admitted to Ashridge CCC, he complained of abdominal pain. It did not record this in the care notes. A paramedic practitioner saw Mr Y about his pain.
15. Later that day, Mr Y complained of shortness of breath in addition to the stomach pain, but staff did not check him until two hours later when they called an ambulance. Mr Y was admitted to hospital where, sadly, he died three days later.
16. Mr X met with the home manager. He raised several matters which included discrepancies in the dates and times of events in the Care Provider’s records. He raised problems such as bread not available or stale, and Mr Y receiving food he had not ordered and the public use of Mr Y’s image without consent. He acknowledged that staff were mostly thoughtful, considerate and caring.
17. One week after Mr Y’s death, the Care Provider responded to Mr X’s complaint but Mr X was not satisfied with this. On 31 March, he wrote to the manager saying he did not agree with her findings and asked for documentation.
18. On 5 July 2019, the Care Provider’s Operations Manager responded to Mr X’s complaint. She acknowledged and apologised that the recording was not satisfactory in respect of the abdominal pain. She said she had discussed this with the home manager and agreed that staff would receive further training in accurate recording in care notes. She said staff may have checked Mr Y but not recorded this. She said they would speak to the staff about the importance of accurate record keeping including of checks when residents are unwell.
19. I have not completed any further investigations into these issues because it would not be proportionate. This is because Mr Y was only in the home for two weeks and the Care Provider accepted its recording was not adequate. It also accepted its records did not evidence that staff checked Mr Y over the two hours after he complained about shortness of breath.

Did the Care Provider’s actions cause injustice?

20. The Care Provider’s failure to record the abdominal pain in the morning may have affected its response to Mr Y’s shortness of breath in the afternoon. On the balance of probability, I have concluded this caused Mr Y an increased risk of harm.
21. The Care Provider’s failure to monitor Mr Y more closely when he complained of shortness of breath probably caused him some anxiety. He was alone and without comfort or reassurance when he was seriously unwell. The Care Provider suggests this was potentially due to staff not recording checks but without a record, or other evidence, we must assume no check was made. Sadly, we cannot now put this right for Mr Y but since he did not receive the service for which he paid, a proportionate refund of fees is appropriate.
22. The Care Provider did not adequately address Mr X’s complaints about the food and the conflicting information in the records; its final response took too long. This caused Mr X some frustration. Since the Care Provider has accepted some flaws in its recording, I am satisfied that, on the balance of probability, Mr X’s complaints about this were justified.
23. As I have identified potential breaches of regulations 16 and 17, I will send a copy of the final decision to the CQC.

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Final decision

26. I have completed my investigation and uphold Mr X’s complaints that the Care Provider:
• failed to check Mr Y, for two hours when he was short of breath and had stomach pain;
• Handled Mr X’s complaint about this poorly; and
• Did not keep adequate records.
27. I am satisfied that in completing the agreed actions, the Care Provider will remedy the injustice as far as possible.

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Investigator's decision on behalf of the Ombudsman