Summary: We upheld some of Ms X’s complaints about her late mother Ms Y’s care in a care home. There was a failure to correctly interpret the signs Ms Y’s health was declining. There was also a failure to meet some of her needs around personal care and poor record-keeping. The Care Provider has already arranged training for relevant staff and apologised. It will offer a further apology to Ms X and review some of its record-keeping procedures.

The complaint

1. Ms X complained about Rectory Court Care Home Ltd (part of Cinnamon Care Collection) (the Care Provider). She said:
1. Staff did not response appropriately to her concerns about a decline in her late mother Ms Y’s health and did not take action to ensure Ms Y received timely emergency medical care
2. There were inadequate measures in place to protect Ms Y against another resident who was aggressive
3. Staff did not meet Ms Y’s needs around personal care: hair washing, soaking her feet or trimming her nails. And they did not cream her legs.

Ms X said this caused avoidable distress.

2. Ms X also complained about:
1. Medication recording issues
2. Concerns about another resident
3. Data breaches.

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What I have investigated

3. I investigated the complaints in paragraph one. My reasons for not investigating the complaints in paragraph two are at the end of this statement.

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The Ombudsman’s role and powers

4. 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)
5. We provide a free service, but we use public money carefully. We do not start or may decide not to continue with an investigation if we decide there is not enough evidence of fault to justify investigating. (Local Government Act 1974, section 24A(6), as amended)
6. We normally expect someone to refer the matter to the Information Commissioner if they have a complaint about data protection. However, we may decide to investigate if we think there are good reasons. (Local Government Act 1974, section 24A(6), as amended)
7. We may investigate complaints made on behalf of someone else if they have given their consent. (Local Government Act 1974, section 26A(1), as amended)
8. 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)
9. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share the final decision with CQC.

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How I considered this complaint

10. I considered Ms X’s complaint to us, the Care Provider’s response to the complaint and health and care records from the Care Provider and Ms X set out later in this statement. I discussed the complaint with Ms X,
11. Ms X and the Care Provider had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Relevant law and guidance

12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) We consider the 2014 Regulations and the Guidance when determining complaints about poor standards of care. Those relevant to this complaint are:
• Regulation 10 says people using care services should be treated with dignity and respect including ensuring privacy and autonomy.
• Regulation 9 requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
• Regulation 13 requires a care provider to have effective systems to safeguard people from the risk of abuse.
• Regulation 12(i) says a care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents.

• Regulation 17 requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.
• Regulation 18 requires a care provider to have qualified, competent, skilled and experienced staff who have received appropriate support and training to enable them to carry out their duties.
5. The Care Provider has a sepsis awareness policy and procedure. This notes residents over 75 who have impaired immune systems, including those taking drugs for rheumatoid arthritis may be at higher risk of developing sepsis. Soft signs of deterioration include: changes in behaviour, mood, appetite and sleeping. The policy said staff needed to pay attention to concern expressed by the resident or their carer and it recognised people may have non-specific presentations. They may have a change in mental state, such as confusion. The GP, 111 or an ambulance can be called at any time and staff responsible for assessing a person’s health needs should have received relevant training in sepsis awareness and management.

What happened

14. Ms Y lived in the Care Home between September 2020 and March 2021. She had dementia, rheumatoid arthritis and Chronic Obstructive Pulmonary Disease (a lung condition). Ms Y was independent with toileting, eating and drinking and needed assistance with showering. She had some memory loss.

Care plans

15. The Care Home kept care plans for Ms Y which were reviewed and updated each month. I have summarised relevant parts below:
• Her daughter would like Ms Y’s hair to be washed three times a week, but Ms Y preferred the hairdresser to do this when on site. Ms Y would decide if she wanted her hair washed when she was in the shower.
• Staff were to apply cream to her arms and legs each day
• Staff were to soak her feet in warm water twice a week and clean them
• Ms Y was to see the chiropodist every six weeks. The records indicate the chiropodist was planned to visit at the start of January 2021
• Ms Y got nervous around some residents due to an incident with one and would like a member of staff to support her to feel safe. If the other resident was unable to be moved away from Ms Y, then staff were to assist Ms Y to another area.
16. There was an unwitnessed altercation between Ms Y and another resident, Ms Z. The report of the incident said Ms Y told staff Ms Z had scratched her arm. The Care Home documented and photographed her injuries, cleaned the wounds and gave Ms Y emotional support. The wounds were monitored and photographed weekly and appear to have healed after a few weeks. Staff reviewed Ms Z’s care plan to include interventions to minimise the risk of incidents. There were further incidents of verbal aggression from Ms Z to Ms Y where staff separated them or tried to keep them apart to avoid escalation.
17. The Care Home kept charts of hair washing and cream application. The charts in February and March 2021 showed Ms Y had her hair washed at least one a week, but there was a gap of two weeks in February where no hair washing was recorded. The chart showed staff applied cream each day apart from a week in February. Ms X emailed the deputy manager in February saying Ms Y’s leg was dry and flaky. The manager made a record of a call with Ms Y saying the cream would be applied and documented.
18. None of the care records for February and March 2021 evidence staff soaking Ms Y’s feet. In the middle of February, Ms X emailed the deputy manager and asked about cutting Ms Y’s nails and about whether staff were washing Ms Y’s hair as the hairdresser was not attending. The email also asked about foot soaking being on the care plan.

8 March 2021

19. On the evening of 8 March 2021, Ms Y became unwell and was admitted to hospital in an ambulance. There are different sources of information about what happened on the night and some differences between the accounts of staff and Ms X’s recollections of the exact words said during telephone conversations. Not all telephone calls appear to have been captured in the care records. I have summarised the evidence below, noting the source.
20. Ms X told us she went into the Care Home at around lunch time on the 8th and spoke to one of the administration staff, she spoke to Ms Y but did not see her. The Care Home has no record of this. A statement from the administrator said she recalled speaking to Ms X and Ms X saying Ms Y was not herself and she (the administrator) reported this to a member of the care team.
21. The daily records indicated Ms Y attended some activities in the afternoon. The nutrition records stated she did not have much to eat in the evening compared with her usual intake, but it was also noted in the Care Provider’s complaint response she’d had sandwiches and cakes during the afternoon, so may not have been hungry.
22. Ms X said in her complaint to the Care Provider that she phoned Ms Y at 22.20 and the latter could not get her words out and was gasping and crying. Ms X said she thought her mother was having a stroke or a seizure.
23. Ms X said her partner phoned the team leader at 22.24 and she also phoned him at 22.28. Ms X described the team leader as dismissive on the phone. Ms X said he refused to go and see Ms Y as he was doing the medication round. The team leader denied refusing to go and see Ms Y.
24. The Care Provider’s second complaint response said Ms X called at 22.28 and asked the team leader to see Ms Y. It went on to say the team leader went to see Ms Y and asked if she was ok, checked her vital signs but did not record them and asked another member of staff to check her. There is no entry in the care records timed at 22.28.
25. At 22.43 another member of staff checked Ms Y and she was awake and content.
26. The Care Provider’s second complaint response said a member of staff was with Ms Y at 22.50 when she vomited. They called the team leader who took her blood pressure which was very high. The member of staff did not make an entry in the care records about this. The Care Provider’s complaint response said the team leader thought the blood pressure record may not be accurate and was going to take it again shortly after.
27. Ms X and the deputy manager (who was off duty) exchanged texts at 22.57. Ms X said there was something seriously wrong with her mother. The deputy manager replied to say the team leader said Ms Y’s blood pressure was high, he was with Ms Y and would contact paramedics.
28. At 23.07 the team leader recorded he had spoken to Ms X who told him ‘there is something wrong with Ms Y as she talks differently’.’ The team leader wrote that he had checked Ms Y and she could not follow a normal conversation. The team leader told Ms X it was not urgent, Ms Y was confused and he would observe Ms Y and put her down to see the GP.
29. At 23.17 the team leader took Ms Y’s pulse, temperature, blood pressure and oxygen levels. He noted he called 111 for advice, noting on the phone to 111 that Ms Y had a high blood pressure reading and he also recorded in the care records that he told a care assistant to monitor Ms Y and turn her on her side if she vomited again. The care assistant said in an interview with a senior member of staff at the Care Provider that Ms Y had vomited, but she had not recorded this at the time because she thought the team leader would do it.
30. The NHS’s record of the team leader’s call to 111 is timed at 23.17 and the case summary said a stroke was suspected. The Care Provider’s complaint response said its call logs confirmed the call was made at 23.08 and lasted 8 minutes 24 seconds. The outcome of the 111 call was to send an urgent ambulance.
31. At 23.20, the deputy manager texted Ms X to say the team leader was speaking to the paramedics and would call Ms X shortly.
32. An ambulance arrived shortly after midnight and took Ms Y to hospital.
33. Ms X said when she arrived at the home the paramedic told her Ms Y was likely to have sepsis (a blood infection) and she was advised to ‘say goodbye to her’. The NHS record indicated the paramedic suspected sepsis and/or a stroke.
34. The Care Home’s records indicated the Care Home gave some information about Ms Y’s health problems to the paramedics and Ms X went with her to hospital. The complaint response explained the hospital information pack sent with Ms Y included details of her conditions and up to date medication. The complaint response noted the records had not been populated to say Ms Y had rheumatoid arthritis. (a condition affecting the immune system). The ambulance records stated Ms Y was on the list of patients who were shielding from COVID-19.
35. The Care Home uses the NEWS 2 (National Early Warning System) chart to identify residents who may be at risk of becoming seriously unwell. The system is based on scoring for vital signs (temperature, pulse and oxygen levels). Ms Y’s score was within the low range at 23.00 on 8 March (indicating a low risk of serious illness), although there was no record of her temperature and so this may have affected the score. The Care Home completed NEWS 2 readings twice a day, usually in the morning and at teatime. However, the teatime measurements were not done on 8 March because Ms Y was attending an activity. There are gaps in recordings on the NEWS chart as well for other days in March. This means the scores may not be reliable.
36. Ms Y died on 13 March. Her death certificate said she had meningoencephalitis. This is an infection of the brain and the layer of tissue covering the brain.
37. The Care Provider responded at length to Ms X’s complaint and upheld some parts. It apologised for the points upheld. The letter is too long to set out in full, but I have summarised the main points:
• The team leader’s communication was poor. He should have made a better analysis of the situation and should have spotted soft signs of illness. At the time he had up to date training (a three-day course on assessing and managing rapid decline.) But it could not conclude the outcome would have been any different.
• Cream application was recorded on medication charts and in daily records and recording in two different places caused confusion.
• It accepted Ms Y’s records inaccurately said she had arthritis rather than rheumatoid arthritis: the pack of information sent to the hospital with Ms Y was not updated properly.
38. As a result of the complaint, the Care Provider created a plan of action needed to reduce the risk of recurrence. Actions were:
• All staff read and signed to say they had understood the sepsis policy
• Team Leaders attended clinical skills training (taking vital signs)
• Team leaders attended customer care training
• All staff attended training in sepsis awareness, early detection and care.
• Care plans were updated to ensure inconsistencies in summary information were rectified.
• Team leaders attended training on contemporaneous record keeping
• Night carers attended first aid training.

Findings

Staff did not response appropriately to Ms X’s concerns about a decline in her late mother Ms Y’s health and did not take action to ensure Ms Y received timely emergency medical care

39. The Care Provider already accepted in its complaint response that there was a failure to interpret the documented signs that Ms Y was declining and becoming very unwell. This was fault. It meant there was a delay in identifying the need for urgent medical assistance. The team leader failed to apply the principles he would have learned on the training he had received in identifying and treating declining patients. Ms Y’s care was not in line with Regulations 12(i) and 18 and this was fault. Care was also not in line with the Care Provider’s sepsis policy which emphasised the importance of taking into account carer’s views and soft signs like confusion and other behavioural changes like changes speech and cognition.
40. There was also poor record-keeping in that staff did not document Ms Y had vomited and some phone calls were not recorded contemporaneously. A complete set of vital signs scores was not recorded on the NEWS 2 chart. Key information about Ms Y’s rheumatoid arthritis was not included in the information sent to hospital with her. All of this was not in line with Regulation 17 and was also fault which meant there was a missed opportunity to put together a full picture of what was happening to Ms Y’s health on 8 March 2021.
41. I cannot conclude the outcome for Ms Y would have been different. However, my view is the fault caused Ms X avoidable distress and time and trouble complaining.

There were inadequate measures in place to protect Ms Y against another resident who was aggressive

42. There was no fault. I am satisfied the Care Home took appropriate steps following the altercation by reviewing and amending the resident’s care plan and putting in place measures intended to reduce recurrence. Care was in line with Regulation 13 as the measures minimised the risk of further harm to Ms Y and so safeguarded her as far as was reasonably possible in a dementia care setting.

Staff did not meet Ms Y’s needs around personal care: hair washing, soaking her feet or trimming her nails. And they did not cream her legs.

43. Ms Y’s care plan said she was to have her feet soaked and nails trimmed. There is no record of feet soaking. Ms Y’s care was not in line with the care plan and so there was a failure to act in line with Regulation 9 which was fault.
44. With regard to hair washing, I note there was some conflict between what Ms X wanted for her mother and Ms Y’s expressed preferences on a given day. I note also there was a gap in the records indicating a period of two weeks where Ms Y’s hair may not have been washed but my view is this was not serious enough to be fault. I consider it was appropriate for care staff to check with Ms Y on the day whether she wanted her hair washing and there is nothing wrong with weekly hair washes if this is the person’s preference. Care was in line with Regulations 9 and 10 and there is no fault. I am satisfied staff respected Ms Y’s independence and her autonomy to make daily decisions about her personal care while having regard to Ms X’s views. There was no fault.
45. I note there was some confusion about records with regard to creaming Ms Y’s legs. Ms X reported them being dry and flaky which may indicate a failure to apply cream or just that the condition of the skin was very dry. I am not able to reach a conclusion on a balance of probability that Ms Y’s skin was not creamed. However, the Care Home’s practice of recording creams in two places in the records caused avoidable confusion and this was fault and not in line with Regulation 17.

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Agreed action

46. Where we identify fault in a care provider’s service, we may make recommendations to minimise the risk of recurrence. In this case, I credit the Care Provider for implementing an action plan including additional relevant training for staff and checking information on care plans was up to date, as I have set out in paragraph 38. In addition to the measures already taken, I recommend, within two months of this final decision, the Care Provider reviews its procedures around recording the application of creams so there is no duplication in the records. This will prevent the confusion the Care Provider identified in its response to the complaint.
47. I note the Care Provider has already apologised in its complaint response. I consider it appropriate to recommend a further written apology to Ms X in light of the findings in this statement and the avoidable distress and time and trouble to her. The Care Provider should apologise within one month of this statement.

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Final decision

48. We upheld some of Ms X’s complaints about her late mother Ms Y’s care in a care home. There was a failure to correctly interpret the signs Ms Y’s health was declining. There was also a failure to meet some of her needs around personal care and poor record-keeping. The Care Provider has already arranged training for relevant staff and apologised. It will offer a further apology to Ms X and review some of its record-keeping procedures.
49. I have completed the investigation.

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Parts of the complaint that I did not investigate

50. I did not investigate complaints about:
• The recording of two types of medication because the Care Home gave a full and satisfactory explanation about what had happened and this did not suggest any injustice to Ms Y.
• Concerns about care of another resident because they did not give consent for Ms X to complain on their behalf.
• Data protection breaches because Ms X can complain to the Information Commissioner.

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Investigator's decision on behalf of the Ombudsman