Summary: Mr X’s condition deteriorated while he was at the home for respite care. There is some evidence this was due to poor care and treatment on the part of the care provider. There was also an unexplained pressure sore on discharge which the care provider did not notice. The care provider should apologise to Mr X and Mrs A, pay them a sum in recognition of the distress caused and take steps to improve its processes in several key areas.

The complaint

1. Mrs A (as I shall call her) says the care provider failed to look after her father (Mr X) properly while he was in the care home for a respite stay. She says his deterioration meant he was unable to return home to his own flat and has since been in permanent care.

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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 injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4)) (Local Government Act 1974, sections 34B and 34C)
3. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
4. 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

5. I considered the information provided by Mrs A and by the care provider. Both parties had an opportunity to comment on an earlier draft of this statement and I considered their comments before I reached a final decision.

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What I found

Relevant law and guidance

6. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
7. Regulation 9 says care and treatment of service users must be appropriate, meet their needs and reflect their preferences. It says, “Assessments should be reviewed regularly and whenever needed throughout the person’s care and treatment.
8. Regulation 12 says care must be provided in a safe way for service users;
9. Regulation 14 says the nutritional and hydration needs of service users must be met; it says, “People must have appropriate equipment or tools to help them eat and drink independently”.
10. Regulation 17 requires care provides to keep proper records for each person in their care. The records should be ‘complete, legible, indelible, accurate and up to date’ and ‘include 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…’.

What happened

11. Mrs A says her elderly father, who lived alone in a semi-supported apartment, had become prone to falls. He agreed to have a period of respite in the care home while a care package was put in place to help him manage at home more easily. The care provider says the assessment was completed in person, with both Mr X and Mrs A present. The information recorded was provided by Mr X and Mrs A and based on this information a decision was made that the home could meet Mr X’s needs.
12. The care provider’s moving-in assessment noted Mr X was at risk of falling generally (noting he had fallen within the last three months) and of falling out of bed. He was recorded as being able to use the toilet independently and was continent but needed some support with personal care (bathing or showering). He had no cognitive impairment.
13. Mr X’s completed care plan noted “high risk of falls due to poor eyesight and weakness following a stroke”. It said Mrs A had reported he had been falling at least twice a week before going into the home. It said the option of crash mats and alarm mats in his room was discussed but it was considered that because of his poor eyesight and use of walking aids, it was possible the alert mats would increase the risk of falls and serious injury. It was agreed staff would monitor his mobility and give extra support when he was tired or felt dizzy. The care provider adds that Mr X’s moving in assessment “confirms his cognition was ‘normal’ and had a ‘good understanding’ and as a result understood risk. He chose to attempt to walk independently around his bedroom and to the bathroom.” The care provider says he would use his pendent or shout for staff assistance.

14. Mr X complained to Mrs A within a couple of days of moving into the home that carers were taking too long to respond to his requests for help. The care staff told Mrs A they were still getting used to each other and if care staff were tending to other residents, they may not always be able to assist him immediately. Mrs A said Mr X was used to having a lifeline bracelet, but the care staff said that was not the system used in the home. The care staff showed Mr X the call points in the home. The care staff noted Mrs A said Mr X had “made life hard with previous carers” as he wanted to be at home with her, which was not possible.

Mobility/Falls incidents

15. Mr X had an unwitnessed fall from his bed on 28 October. The care provider reported it to Mrs A. He fell again on 5 November when he was found between the hand basin and the radiator in his bathroom. The care provider called 999 because Mr X had hit his head. The care notes record that while they were waiting for the ambulance, Mr X’s condition changed: he complained of pain in his head and his breathing slowed. The care provider telephoned 999 again to update the call. Mr X was admitted to hospital. He was discharged after a head x-ray and scans with no changes to his medication or care. The home manager’s notes record “Call bell, pendent and floor sensor mats in place in place at time of the fall.”
16. The care provider says “Mr X was noted to be shouting for help or assistance rather than use his call bell. Based on this a pendent was provided on the 24th of October. This remained in place until he was discharged. Following a review of Mr X’s changing needs and the two recorded falls on the 29th of November it was decided floor sensor mats were required. These were put into place and located at each side of his bed”.
17. On 8 November Mr X slipped between the chair and the table when he was trying to sit down for breakfast. He was recorded as being ‘embarrassed’ but with no injuries after being checked over. A carer reported the incident to Mrs A who said she felt Mr X was very confused that day: he had not realised he was talking to her on the telephone. The care notes say, “(Mrs A) feels (Mr X)’s cognition is declining , his eye sight is very very poor to almost none existent & she feels that there may be some signs of dementia appearing.”
18. The notes report no further concerns until 24 November. The care notes record a call from the GP after Mrs A had contacted him about Mr X’s confusion. The care notes say “I have inform GP his behaviour been change but I'm sure is UTI or maybe he get anxious because his going home tomorrow or can be side effects from pain patch .He does shouting , been incontinent once , refused food , refused to give urine sample .GP will prescribe antibiotics for 5 days.”
19. Mr X went home from respite on 25 November but was admitted to hospital again. He was discharged on 26 November. The hospital discharge summary says, “This 92-year-old male presented with dysuria and delirium. History over the last two weeks of delirium and agitation fluctuating throughout the day with hallucinations at times”. The hospital diagnosed urinary retention due to medication and polypharmacy and suggested cessation of one medication. Mr X was discharged back to the care home with a catheter in situ.
20. The care notes continue to record episodes of confusion and noted Mr X had started shouting at care staff, demanding they were with him all the time. On 29 November he was found on the floor in his room at the 3am check and said he had forgotten to use his call bell to get help. The GP saw him later that day at the care provider’s request. Mr X fell again that evening but said he had ‘put himself on the floor’ and would stay till his daughter came or staff stayed with him because no-one was helping him. There was a further similar occurrence on 1 December. The GP consulted with a frailty specialist and decided to prescribe a small dose anti-psychotic.
21. The care notes recorded worsening confusion. Mr X fell again in the early hours of 2 December and was taken to hospital as his head was cut. The discharge note recorded “Recurrent falls – multifactorial causes; constipation”. Another of Mr X’s medications was stopped.
22. Mrs A telephoned the care home to say Mr X would be returning later; she was recorded as saying, “the consultant has confirmed there is no infection but the change in presentation is likely to be delirium possibly caused by constipation or a previous urine infection.”
23. Mrs A arranged for another care provider to assess Mr X as she felt his needs were no longer being met in the home.
24. Mr X fell again on 6 December: on 7 December the care notes read, “(Mr X) has been so confused all night that a staff [member] had to stay by him all night to stop him dropping himself to the floor.” Mr X left the home permanently on 8 December.

The complaint

25. Mrs A complained to the care provider on 13 December. She said her father had entered the home for respite but as a result of his stay, could never now return to his own home. She said he had sustained injuries as a result of many falls and despite asking for an alert mat or call bell to be available to him, she was told he could not have both. She said his cognition had declined because he had gone into urinary retention. She said she had been told by medical staff this was because insufficient fluids had led to constipation. She said he left the home with a pressure sore on his thigh caused by the catheter bag strap rubbing. The care provider maintains that both a pendant alarm and falls mats were provided to Mr X and remained in place until discharge.
26. Mrs A also said Mr X’s fluid intake and output had never been questioned at the care home but the new care provider had called for clinical help soon after his arrival when it became clear his fluid output was significantly below his intake. She said he was in urinary retention again and was back in hospital. She said care staff at the care home had given her the impression Mr X used his call bell too often and alerted them for no good reason.
27. The care provider responded. The regional manager said staff had not felt frustrated by the use of the call bell but had found it difficult to support Mr X as his cognition worsened and he himself was unclear why he had called for help. She noted the possibility of a move to a memory care suite had been discussed.
28. The manager said although Mr X had been assessed as able to use the call system when he was admitted, in fact he was not able to understand its use once in the home. He was provided with a push-button alarm on 23 October but would leave it around his room or on the floor. Following earlier discussions about the possible risk associated with a crash mat because of Mr X’s poor vision, it had been decided to install two alert mats and she said they remained in place until he left.
29. The manager said Mr X’s notes showed he had been eating and drinking well until 24 November and his moving-in assessment recorded he would do so independently. She said there was no requirement therefore for staff to monitor his fluid intake and output or record whether he had opened his bowels as this had not been raised as a possible problem. She said the hospital discharge summary for 25 November did not prescribe laxatives, or record dehydration.
30. The manager said there was no recorded pressure sore on Mr X’s thigh when he left the home. She said a full body map had been competed on 3 December but showed bruising (from a fall) not a pressure sore. She said the Deputy Manager had showered Mr X on the morning he left the home and noted a red mark on the back of Mr X’s thigh but the skin was not sore or broken. She said there were numerous opportunities for staff to check Mr X’s skin when they were removing the catheter bag or assisting with personal care. She asked for more information so she could investigate further.
31. The manager said Mr X had been recorded as having showered at least 8 times during his stay at the home and had, according to care staff, been showered and/or helped with personal hygiene very many more times which were not recorded. She said staff would be reminded of the importance of accurate note keeping.
32. The manager said the care notes showed staff were regularly recording Mr X’s fluid output when he was discharged from hospital with a catheter in place.
33. Mrs A wrote again. She said her father had never been given a falls/alert mat and staff who had reported that he had had misspoken. She said she was told he could have either a call bell or a falls mat. She said she had told the care staff at Mr X’s pre-admission assessment that he suffered from constipation and needed to be encouraged to take fluids but it had not been recorded. She said she had frequently asked for him to be given fluids in a spouted cup (as he dropped open cups so would give up drinking from them) but was told staff couldn’t provide one as ‘it was not in his care plan’. She said it was as though staff couldn’t think for themselves or ask for the care plan to be updated.
34. In addition she gave more information about the pressure sore. She said a pressure sore had been found only hours after her father had been admitted to the new care home and the District Nursing team was called. She said the hospital staff next day confirmed it was a grade 3 sore ‘due to prolonged and sustained pressure from the catheter tube”. She said “The pressure sore is in the fold of skin between his buttock and the top of his leg and therefore I believe it was missed by your staff”. She added she had reported it to the CQC as the regulations required.
35. Finally she said there was little point in staff recording fluid output without recording intake.
36. Mrs A complained to the Ombudsman. She said her father had not shown signs of cognitive dysfunction until he experienced urinary retention while at the care home. She said what happened at the care home meant he could never now return to his own home again.
37. The care provider says “(Mr X) was assessed as being at medium risk of falling. Initially, (Mr X) had the use of the standard call bell but it quickly became apparent that he found this difficult to use. As a result, he was provided with a pendent. In addition, sensor mats were in place and located at each side of his bed.”
38. In respect of the pressure sore, the care provider says “The Deputy Home Manager supported (Mr X) to have a shower on the morning he was discharged and did not see any pressure sores. (Mr X)’s Daughter later informed the home that a wound had been noted. As a result, a body map had not been completed, referrals made etc”.

Analysis

39. There are discrepancies in the care provider’s information. It is agreed Mr X was given a call bell in his room which he found difficult to use. His care plan says he should not have a falls alert mat because of the increased risk of falling it would create: but the care provider says two alert mats were provided. Mrs A says he never had a mat in his room. She says he was told he could not have a call bell and a mat. As the regional manager was relying on reports from staff, and Mrs A was reporting what she herself had seen in her father’s room, on the balance of probabilities it seems likely Mr X was not provided with a falls alert mat.
40. Mr X suffered at least 10 falls in the 7 weeks he was at the home for respite, with the falls increasing in number in the last couple of weeks of his stay. His moving-in assessment and care plan describe him as being at high risk of falls but the care provider’s response to my enquiries says he was a medium falls risk. In any event it is difficult to see what steps the care provider took to monitor and prevent further falls until his last night in the home when a staff member was recorded as staying with him to ensure he didn’t slip out of bed.
41. It is not clear the care provider adequately attended to Mr X’s hydration. Although he was able to eat and drink independently when he went into the home, the care provider does not seem to have responded to any increased needs as the regulations require. Mrs A’s remark that staff could not provide a more suitable cup for her father because ‘it was not in his care plan’ goes to the heart of the complaint.
42. After Mr X was discharged from hospital with a catheter, the care provider monitored his output (sporadically) but not his intake. That did not provide sufficient information to inform his ongoing care.
43. The care staff at the new home, the district nurses and the hospital staff all witnessed a grade 3 pressure sore within hours of Mr X leaving the care home. In contrast the care provider has the report of the deputy manager who showered Mr X that he did not see a sore, only a red mark. It is possible the positioning of the sore made it difficult to see. It is surprising however that care staff had not noted it during routine care and changing the catheter bag, but there is no record on the care notes. On the balance of probabilities it seems likely Mr X developed the pressure sore as a result of poor care in the home.
44. Finally, the standard of record keeping in the home was not of the standard expected. There is doubt whether the pre-admission assessment contained all the information Mrs A provided which would have made a difference to the way Mr X’s care and treatment was provided. The care provider also acknowledges the notes were incomplete.

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Agreed action

45. Within one month of my final decision the care provider will offer an apology to Mr X and Mrs A for the poor standard of care and treatment during the 7 weeks he was in the home;
46. Within one month of my final decision the care provider will take steps to review the way in which staff respond to the changing needs of residents;
47. Within one month of my final decision the care provider will review its falls policy especially in respect of the way it responds to increased numbers of falls;
48. Within one month of my final decision the care provider will remind staff of the requirement to collect information accurately (for instance, fluid intake and output as in this example) if it is to be useful;
49. Within one month of my final decision the care provider will let me know the steps taken to improve record keeping.
50. It is not possible to conclude Mr X’s deterioration was solely or completely due to the care in the care home but Mrs A is left with the distress of not knowing if her father would have deteriorated so significantly were it not for the poor care he received. Within one month of my final decision the care provider will pay the sum of £1000 to Mr X (care of Mrs A) to use for his benefit, and the sum of £500 to Mrs A to recognise the distress caused to her.

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Final decision

51. I have completed this investigation. I find the actions of the care provider caused injustice to Mr X and Mrs A, which the completion of the recommendations at paragraphs 45 – 50 will remedy.

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Investigator's decision on behalf of the Ombudsman