Summary: Miss D complains about the care her late mother received at one of the provider’s care homes. The Ombudsman has found some fault in record-keeping, causing uncertainty to Miss D, but there was no fault in the care provided.

The complaint

1. Miss D complains about the care her late mother, Ms J, received from September 2018 to December 2018. Miss D says her mother was living in poor, inhumane conditions, causing emotional distress and trauma.
2. In particular, Miss D says the care provider failed to:
• deal appropriately with Ms J's seizure in September 2018, sending her to hospital alone, leaving her in blood-stained clothing on her return, and not responding to the family's queries about the incident
• meet Ms J's nutritional and hydration needs, causing significant weight loss and a deterioration in her health
• treat her with dignity and respect, as her clothes, bedding and furniture were saturated in urine, faeces and flies and she was inappropriately dressed
• refer her for medical/NHS support and failed to administer medication, causing broken skin and a deterioration of her health
• properly assess the risk of falls from bed
• move her into nursing care when it could not meet her needs

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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. We normally name care homes in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home. (Local Government Act 1974, section 34H(8), as amended)
6. We normally expect someone to complain to the Care Quality Commission about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended)
7. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (section 26A or 34C, Local Government Act 1974)
8. 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.
9. 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)

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How I considered this complaint

10. I spoke to Miss D about her complaint and considered the information she sent and the Provider’s response to my enquiries. The length of our investigation was affected by the coronavirus pandemic.
11. Miss D and the Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Fundamental Standards of Care

12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set 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. The standards include:
• Person-centred care (Regulation 9): The service user must have care or treatment that is tailored and meets their needs and preferences. Providers must involve a person acting on the service user’s behalf in the planning of their care and treatment.
• Dignity and respect (Regulation 10): Service users must be treated with dignity and respect and in a caring and compassionate way.
• Safe care and treatment (Regulation 12): Providers must do all that is reasonably practicable to mitigate risks to the service user’s health and safety. The provider must have arrangements to take appropriate action if there is a clinical or medical emergency.
• Safeguarding from abuse (Regulation 13): Service users must be protected from abuse and improper treatment, this includes neglect.
• Food and drink (Regulation 14): Service users must have enough to eat and drink to keep them in good health while they receive care and treatment.
• Premises and equipment (Regulation 15): Providers must make sure that the premises where care and treatment are delivered are clean, suitable for the intended purpose, maintained and where required, appropriately located.
• Good governance (Regulation 17): Providers must maintain securely an accurate, complete and contemporaneous record in respect of each service user.
13. The Body Mass Index (BMI) assesses a person’s weight in relation to their gender, height and age. The Malnutrition Universal Screening Tool (MUST) combines data about a person’s BMI and unplanned percentage weight loss to produce an indicator of risk of malnutrition. A MUST score of 1 indicates medium risk, a MUST score of 2 or above indicates high risk.

What happened

14. Ms J had dementia and depression and required assistance in all areas of daily living. In April 2018 she moved to Park View Care Centre (the Home), which is a residential care home operated by Ranc Care Homes (the Care Provider). Ms J attended a day centre twice a week.
15. Ms J’s care plan says two carers were needed to help Ms J with personal care and one to assist with eating and drinking. She had medication, including moisturiser to be applied daily. The care plan says if Ms J refused care, staff should try again later. Ms J was unable to use the call bell, so required hourly wellbeing checks. Her mobility care plan says Ms J did not always lie in a safe position in bed. A crash mat was in place and the bed was lowered.
16. In September 2018 Ms J had a possible seizure and went into hospital. Miss D says she was sent to A&E on her own and was left in clothes covered in blood for many hours after returning to the Home. Miss D says the Home has not told the family about the cause of the seizure or whether any treatments were needed afterwards.
17. The Home’s daily care records for that day say she went to hospital at about 4.25am following a possible seizure. There is no description of the incident. Ms J was back by 10.30am, the records say she had blood on her T shirt but did not want to change her clothes. There is no reference to the cause of the blood. The family visited Ms J and she later ate lunch. There is evidence the Home faxed Ms J’s GP to inform them of the incident. However, the records for the hourly wellbeing checks for that day are wrong; they say Ms J was in bed all night, had a shower at 7am and breakfast at 8.30am.
18. Miss D says Ms J became extremely depressed after this and said she was not happy in the Home. Miss D became concerned about the care Ms J was receiving. She says Ms J was positioned lying down on her side while eating, food was rarely eaten, drinks were left for days and there was no monitoring. She had also found Ms J almost falling from the bed, struggling to re-position herself. Miss D told the Home Ms J needed 1:1 care but the Home had said there was not enough staff.
19. The Home’s records show Ms J was often resistant to care offered by staff and could at times become verbally and physically aggressive if carers persisted. There is reference to her being very depressed and having low moods.
20. Her medication record shows the GP prescribed an anti-depressant on 6 October 2018, though I have seen no record of a GP visit or any other details. Ms J started to refuse to take any medication from mid-October onwards.
21. There was an incident on 18 October 2018 when Ms J sat on the floor for most of the day and refused to move. The next day she was unable to stand properly and complained of pain in her leg. The Home’s records say they called the GP who visited and prescribed antibiotics for an infection in her leg. I have seen no records of any discussion about Ms J’s refusal of care. There is a note that the community mental health team would visit the following week, but there is no evidence they did so.
22. From late October 2018 Ms J started to refuse to eat; even on the days she ate, she ate very little. She also drank very little. The records show carers continuing to offer care and meals. They also note two incidents when a carer found Ms J “half out of bed” and that she frequently did not want to get up or leave her room.
23. The Home faxed the GP on 5 November 2018 asking about a referral to the community mental health team. They called the mental health team on 13 November 2018, which said no referral had been received. The Home again faxed the GP on 20 November 2018 about this. The GP told the safeguarding investigation they had no record of the Home asking them to refer Ms J to the community mental health team.
24. Miss D says when she visited on 21 November 2018, she found clothes, bed sheets and furniture soaked in urine, faeces and flies. Ms J was inappropriately dressed and had not taken her anti-depression medication. The care records show the day before Miss D’s visit carers had given Ms J a full body wash and changed her bedding. On the day of the visit Ms J was refusing personal and continence care and did not want to leave her bed.
25. The GP visited on 23 November 2018; the note only says he requested a blood test.
26. The Home weighed Ms J on 24 November 2018 and found she had lost 14kg in two months, giving a MUST score of 4. It referred Ms J to a dietician, speech and language therapist and the mental health team. From the last week in November Ms J refused food every day and drank very little.
27. Miss D complained to the Home on 28 November 2018 about:

• soiled bedding and clothing
• unexplained marks and bruises
• medication not being provided
• no concern for client’s dignity
• mental health needs not being met
• poor nutrition
• risk of injury from falling from bed

28. She also complained to the local Council which started an adult safeguarding investigation.
29. The Home replied to the complaint on 17 December 2018. It said:
• Ms J was refusing all care offered. She had been scratching herself due to dry skin but would not always allow staff to apply creams.
• Ms J was refusing to open her mouth for food, fluids and medication. Staff were unable to force her and the GP had been informed.
• The meals were a well-balanced diet and staff assisted Ms J to eat at all mealtimes, but she was refusing to open her mouth.
• Ms J had not had any falls or fallen out of bed. The bed was very low and a crash mat was in place. Bed rails were not used for people with dementia.
• Ms J now required nursing care.
30. Ms J fell out of bed on 19 December 2018. A risk assessment for a bed rail was carried out which found that Ms J’s dementia made it too risky to have a rail.
31. Miss D was concerned Ms J was unwell on 21 December 2018 and contacted the NHS 111 service, which subsequently sent an ambulance. Ms J was taken to hospital and found to be severely dehydrated and in late stage dementia. Miss D gave notice to the care home. Ms J sadly passed away in hospital in February 2019.
32. In March 2019 Miss D sent the Council a letter from the day centre which raised concerns about the care Ms J and other residents received at the Home, noting incidents when Ms J had arrived incontinent without a pad. The letter said the Home had refused to allow the day centre to pick Ms J up.
33. Miss D said the Coroner had raised concerns about Ms J’s death and would be undertaking a post-mortem. The Coroner did not deem it necessary to hold an inquest into Ms J’s death. The Council concluded there was no evidence that abuse or neglect occurred and the decline in Ms J’s health could not be attributed to actions of the Home.
34. Miss D complained to the Ombudsman in November 2019 about the quality of care in the Home. She also complained separately about the Council’s safeguarding investigation. We found no fault by the Council. The Home has subsequently been seeking payment for Ms J’s care from her estate.

My findings

35. I have reviewed the Home’s records for Ms J’s care from September 2018 to December 2018. I have also seen the Council’s safeguarding report. This says the Home had determined Ms J did not have capacity to make decisions about her care.
36. I have seen no medical records from the hospital or GP about Ms J’s suspected seizure, so I cannot say what happened. Miss D would need to approach Ms J’s GP to find out more as the Local Government and Social Care Ombudsman has no jurisdiction over GPs or hospitals. I would not expect the Home to have provided Miss D with any medical information about a diagnosis or treatment.
37. However, I find the Home’s notes about the incident are cursory. There is no description of the incident or reason given for the blood on Ms J’s top. In addition, the record of the hourly wellbeing checks for this day is wrong, showing Ms J to be in the Home when she was in fact in hospital. I find there is fault in record-keeping, which has caused uncertainty to Miss D and the family.
38. The records show Ms J’s mood declined from mid-September 2018 onwards, causing her to refuse food, drink, medicine and personal care.
39. If a person refuses food, I would expect the home to keep records of food and fluid intake, inform the family, and refer to the GP. Carers should continue to offer food and offer alternative snacks or foods with high nutrient value.
40. The CQC’s fundamental standards say care providers must follow people's consent wishes if they refuse nutrition and hydration, unless a best interests decision has been made under the Mental Capacity Act 2005, and action must be taken without delay to address any concerns.
41. The records show carers continuing to offer Ms J food, in line with her care plan. There was contact with the GP on 6 October 2018, although it is not clear from the Home’s records whether Ms J’s refusal to eat was discussed. There is evidence the Home faxed the GP on 5 November and asked about a referral to the community mental health team. They chased this up twice over the next two weeks. The Home started to monitor Ms J’s food and fluid intake after 24 November, when the MUST score of 4 was recorded, and referred Ms J to the dietician. This is in line with guidance.
42. The Home took all the actions I would expect in relation to Ms J’s refusal to eat and I do not find fault. However, the records of discussions with the GP should have been more detailed.
43. The Home says Ms J refused to attend the day centre, but the daily records do not record this, they only have occasional references to Ms J attending day care.
44. The records show carers found Ms J lying at the edge of the bed. A crash mat was in place and the Home carried out a risk assessment which determined a bed rail was not safe. I do not find fault.
45. Ms J was refusing personal care almost every day from October 2018. The Home says it is not acceptable to force a resident to do something that they refuse to do. This is correct. The law says it must be first assumed a person can make their own decisions and they have a right to refuse care and treatment.
46. Ms J did not have capacity to decide about her care and, as neglecting someone's personal care needs can put someone's health at risk, the Home may have taken a best interest decision to compel Ms J to have showers. But I cannot see that this would have maintained her dignity. The records show that on the occasions when carers did try to compel Ms J she became very distressed.
47. The evidence shows the Home followed the care plan in place, which was to continue to offer personal care to Ms J. I can see this was a very distressing period as Ms J’s condition deteriorated, but there was no fault by the Home.

Agreed action

48. Within a month of my final decision, the Care Provider has agreed to:
• Apologise to Miss D for the uncertainty caused to her by its poor record-keeping in September 2018
• Review its processes and remind staff to ensure it keeps adequate records, in particular about GP visits

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Final decision

49. There was fault in record-keeping. The actions the Care Provider has agreed to take remedy the injustice caused. I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman