Summary: Ms C complains the Care Provider failed to support Mrs D which resulted in her premature death. The Care Provider failed to record decisions, follow care plans, monitor Mrs D’s nutrition needs, and properly respond to Ms C’s complaints. Ms C has the uncertainty of not knowing, but for the faults identified, whether Mrs D’s health would have deteriorated. The Care Provider has agreed to apologise for the failures identified and pay Ms C £500 for her time, trouble, and avoidable distress. It will also review policies, remind, and if necessary provide training to staff members about daily recording, updating risk assessments and care plans; and responding to complaints.

The complaint

1. The complainant, who I refer to as Ms C, complains about services provided to her late mother, who I refer to as Mrs D, at Henley House Care Home; managed by Greensleeves Care Trust, the “Care Provider”.
2. Ms C complains the Care Provider failed to put in measures to prevent Mrs D falling and provide suitable care. Ms C says this led to Mrs D injuring herself and eventually her death.

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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 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

6. I spoke with Ms C and considered information she provided. I wrote to the Care Provider asking questions and for information. I considered:-
• Mrs D’s care records and complaint correspondence;
• 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. I have used the fundamental standards as a benchmark for considering this complaint.
7. Ms C and the Care 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

8. Mrs D went into the care home from the community where she was supported by her daughter. Mrs D moved in with her husband who I call Mr D.

What should have happened

9. 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.
10. Regulation 9 “Person Centred Care” says care providers should enable and support relevant people to make or participate in making, decisions relating to the service user's care or treatment to the maximum extent possible.”
11. Regulation 10 “Dignity and Respect” says people using services should always be treated with respect and dignity when they are receiving care and treatment.
12. Regulation 12 “Safe care and treatment” is to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Care providers must assess the risks to people's health and safety during any care or treatment and act to mitigate risks.
13. Regulation 14 “Meeting nutritional and hydration needs” says care providers must meet service user’s nutritional and hydration needs. The associated guidance says care providers:-
• “must include people's nutrition and hydration needs when they make an initial assessment of their care, treatment and support needs and in the ongoing review of these. The assessment and review should include risks related to people's nutritional and hydration needs. Providers should have a food and drink strategy that addresses the nutritional needs of people using the service.”
14. Regulation 15 “Premises and equipment” says equipment that is used to deliver care and treatment is clean, suitable for the intended purpose, maintained, stored securely, and used properly.
15. Regulation 16 “Receiving and acting on complaints” care providers must have an effective and accessible system for identifying, receiving, handling and responding to complaints. All complaints must be investigated thoroughly and any necessary action taken where failures have been identified.
16. Regulation 17 “Good governance” 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

17. Mrs D moved into the care home on 11 May 2021. Ms C says the Care Provider completed a pre-admission assessment via zoom which included Mrs D’s mobility needs. Ms C says she told the Care Provider that Mrs D needed someone with her at all times when she was walking and regular urine checks for potential Urinary Tract Infections.
18. Ms C says the Care Provider gave Mrs D a room opposite to Mr D, but at the end of a long corridor which made walking to and from the lounge difficult and dangerous. Ms C says she would not have accepted this room had she known its position. Ms C says the care home agreed to change Mrs D’s room when another room became available. The Care Provider says Mrs D later refused a different room as she wanted to stay close to Mr D. The Care Provider accepts it has no records about the room change.
19. Ms C says during the first week she told senior care staff Mrs D needed a wheelchair to get to communal areas as Mrs D was struggling. Ms C says care staff disagreed and felt Mrs D could manage without a wheelchair.
20. Mrs D’s care plan says, “Staff are to support Mrs D when mobilising by walking with her for reassurance and support. For longer distances use the wheelchair and for trips out. Staff to monitor mobility daily and report any changes or concerns to senior on duty. Staff to alternatively use hoist if Mrs D unable to stand up.”
21. On 23 May Mrs D had a fall outside her room, it took four hours for paramedics to arrive. The incident report says staff should review the falls risk assessment and mobility care plan and follow up concerns Mrs D may have a urine and chest infection. The Care Provider changed the care plan and recorded that Mrs D now needed a wheelchair to get to communal areas. Ms C says although the care home agreed to support Mrs D with a wheelchair she often witnessed Mrs D walking unaided and had to remind care staff.
22. On 6 June Mrs D fell in her room. Care staff at the time said this may have been caused by the sensor mat. The Care Provider later said this was not the case but did review the sensor mats and contracted with a new supplier.
23. Following this fall Ms C says Mrs D’s general health worsened, she had lost weight, was not eating much, and had become frail. She also:
• found stale urine in Mrs D’s room, water jugs unchanged and not filled with Mrs D’s preferred drink;
• on 11 June Ms C found Mrs D drenched in urine when supporting her to get up at 11 a.m.;
• found Mrs D upset after two male carers completed personal care. The Care Provider says it sought Mrs D’s permission at the time and had little choice because of a lack of staff caused by the pandemic;
• raised concern the Care Provider failed to call a GP when Mrs D’s temperature was over 37 degrees. The Care Provider says a GP was not necessary as Mrs D’s temperature reduced shortly after;
• raised concern that Mrs D developed a preventable pressure sore on her foot.
24. Ms C says a district nurse was so concerned about Mrs D’s weight loss and general health she called the GP.
25. The Care Provider made a referral to the dietician on 17 June and an urgent referral on 1 July after Mrs D continued to lose weight. On 3 July care staff recorded Mrs D’s temperature as over 38 degrees, a short time later at 14.22 this had reduced to 36.6 degrees. There are then no care entries until 22.33 where carers record Mrs D as sleeping.
26. On 4 July Mrs D went into hospital. She died the following day. Ms C says the cause of death was sepsis, a urine infection and fragility.
27. Ms C complained to the Care Provider, she received an initial response, but remained unhappy. The Care Provider sent a second response apologising for the lack of empathy, apology, or reassurance for future improvements in the first response. The Care Provider agreed to provide training for managers in complaint handling; have clearer communication with the sales team; encourage face to face preadmission assessments and have regular care review meetings with residents and families.

Is there fault causing injustice?

Falls

28. The Care Provider’s falls care plans and risk assessments are unclear. There is no link between care planning around the risks identified and how they changed overtime. This is fault and a potential breach of Regulations 12 and 17.
29. The Care Provider says staff did not always support Mrs D with a wheelchair as her mobility was better on some days and Mrs D refused help. While this is a person centred approach and in line with Regulation 9, care staff should have recorded decisions which were not in line with Mrs D’s risk assessment and care plan. The failure to record these decisions is fault and a potential breach of Regulation 17.
30. The Care Provider is at fault for failing to properly assess the use of the sensor mat which may have been contributary in Mrs D’s second fall. This is a potential breach of Regulation 15. While the Care Provider has taken action to change the contractor used for the sensor mats there appears to be no risk assessments for individual residents.
31. There is not enough evidence for me to say on balance Mrs D would not have fallen had the Care Provider acted without fault. The care records show Mrs D was walking without a wheelchair but with the support of care staff or at times her husband. Mrs D was also offered an alternative room which she refused. Ms C does however have the uncertainty of not knowing whether but for the faults identified above Mrs D would have fallen.

Appropriate support for nutrition, pressure sore area, events of 11 June, and contacting health professionals

32. The Care Provider assessed Mrs D as high risk of pressure sores and provided suitable pressure relieving equipment. This is in line with Regulations 12 and 15. However the care plan says care staff should check Mrs D’s skin daily. There is no evidence of this in the daily care records. This is fault and a potential breach of Regulation 17.
33. Similarly there is no evidence staff checked Mrs D on 11 June from 6.52am to 11 am when Ms C arrived and found her soaked in urine. This is fault and a potential breach of regulation 12. Although the length of time Mrs D was in this situation is unknown it would have been distressing for both Mrs D and Ms C.
34. The action plans/care plan changes linked to assessments for Mrs D’s nutrition is unclear. There is evidence the Care Provider made referrals to the dietician. It completed food and fluid monitoring charts from 1 July and provided Mrs D with a fortified diet to improve her nutrition. However there are no nutrition charts between 22 June and 1 July, this is after the Care Provider had concerns about Mrs D’s weight. I consider this delay amounts to fault and is a potential breach of Regulation 14.
35. The Care Provider says it did not call a GP when Mrs D’s temperature exceeded 38 degrees as it quickly reduced to an acceptable level. However at this time Mrs D’s condition was deteriorating, she was lethargic and not eating. The Care Provider took no additional steps to check Mrs D’s well being or gain advice. It was only in the morning when care staff observed redness on Mrs D’s heal was a district nurse called. This is fault and a potential breach of Regulation 12.
36. As a result of these failures Ms C has the uncertainty of not knowing whether Mrs D would have deteriorated to the extent she did, and anger the care provided was not always at the required level.

Complaint handling

37. The Care Provider accepted failings as described in paragraph 27. However the first response did not include a clear apology about the Care Provider’s failings and the actions it would take. The second response although improved did not address all Ms C’s complaints. This is fault and a potential breach of Regulation 16.
38. As a result Ms C had time and trouble in contacting the Care Provider again. She also had the frustration the Care Provider was not listening to her complaints or responding properly.

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Agreed action

39. I have found fault in the actions of the Care Provider. As Mrs D has now passed away I cannot remedy her personal injustice. My recommendations are therefore to improve future practice and remedy Ms C’s personal injustice. The Care Provider has agreed to my recommendations to:-
1. apologise to Ms C for the faults identified and the distress and uncertainty this has caused her;
2. pay Ms C £500 in acknowledgement of the faults identified and the time, trouble, uncertainty, and anger this has caused her;
3. review how staff complete care plans and risk assessments so it can evidence a clear link between a change in need and a corresponding change in the care plan an risk assessment;
4. remind staff about properly recording dates and conversations with family members;
5. remind staff about properly recording interventions including actions contained in care plans and where residents are agreeing to or requesting interventions that are contrary to their care plan;
6. ensure there are individual risk assessments in place for the sensor mats currently used.
40. The Care Provider should complete actions (a) and (b) within one month of the final decision and (c) to (f) within three months of the final decision.

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Final decision

41. I have found fault in the actions of the Care Provider which has caused injustice. I consider the agreed actions above are suitable to remedy the complaint. I have now completed my investigation and closed the complaint.
42. 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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Investigator's decision on behalf of the Ombudsman