Summary: Mrs X has complained about the care her husband, Mr X, received from a care provider, causing him to deteriorate rapidly. Mrs X also complained the Care Provider was critical of the care she had provided him. We find the Care Provider at fault for failing to take and keep full records, and for failing to contact Mrs X following a change in Mr X’s behaviour. We recommend the Care Provider apologise to Mrs X, make a payment for uncertainty and distress, and take action to prevent recurrence.

The complaint

1. Mrs X complains about the care her late husband, Mr X, received while resident at a care home for a week’s respite care. Specifically, Mrs X has said the Care Provider:
• Failed to give Mr X appropriate food or monitor his fluid intake.
• Failed to contact Mrs X or the relevant healthcare professionals when Mr X’s mobility deteriorated and failed to identify a UTI he developed during his stay.
• Was critical of the care she had given to Mr X and tried to scare her into leaving Mr X at the care home for longer than necessary.
• Gave wrong information to a district nurse and social services which delayed Mr X’s return home.

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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 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)
3. We consider whether there was fault in the way an organisation made its decision. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
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)
5. 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

6. I spoke to Mrs X and considered all the information she provided. I also considered all the information the Care Provider provided.
7. Mrs X and the Care Provider had an opportunity to comment on a draft decision. I considered any comments received before making a final decision.

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What I found

Care home regulation and guidance

8. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers which meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC had guidance on how to meet the fundamental standards.
10. The CQC issues guidance on the regulations.
11. In respect of Regulation 9 it says care providers must actively seek the views of people who use their service and those lawfully acting on their behalf, about how care and treatment meets their needs. Providers must be able to demonstrate they acted in response to any feedback.
12. In respect of Regulation 13, it says care providers must act without delay to notify the appropriate bodies where it suspects any form of abuse or improper treatment.
13. In respect of Regulation 14, it says care providers must ensure people have enough to eat and drink to meet their nutrition and hydration needs and receive the support they need to do so. Where a person is assessed as needing a specific diet, this must be provided in line with that assessment. Nutritional and hydration intake should be monitored and recorded to prevent unnecessary dehydration, weight loss, or weight gain.
14. In respect of Regulation 17, it says care providers must maintain accurate, complete, and detailed records for each person using their service.

What happened

15. Mr X suffered with Parkinson’s and dementia and entered a care home, Bowbrook House, for a weeks’ respite care in February 2022 while his wife visited family. This was arranged by Mrs X, who held Lasting Power of Attorney for Health and Welfare for Mr X.
16. The Care Provider completed a pre-admission form with Mr X before he entered the care home. The pre-admission form recorded that Mr X needed help to stand but could walk with the use of a walking frame and only occasionally used a wheelchair. It also recorded Mr X needed help to get to the toilet, to dress and take care of his personal hygiene, and needed soft foods. The form noted Mr X had continence issues and was prone to both UTIs and diarrhoea. The form recorded Mr X required cream on pressured areas of his skin and used an air flow pressure mattress. The pre-admission forms specified Mr X needed assistance with food and drinks.
17. Mr X entered the care home on 21 February. At this point, staff carried out general risk assessments for Mr X and specific assessments for the risk of falls, movement issues and the need for bed rails, as well as creating a personal emergency evacuation plan for him.
18. The care notes completed during Mr X’s stay show staff checked on him regularly to check his well-being, personal hygiene, toilet needs and sleep. The notes show staff ensured Mr X was taking his medication as he should be, and Mrs X was in contact to make sure he had settled in well. The notes do not record all Mr X’s meals, but sporadically state when he had eaten well.
19. On 21 February the notes show Mrs X called to see how Mr X had settled. Staff told Mrs X he kept taking food out of his mouth, so she reminded staff he needed food that did not need much chewing.
20. The notes show on 23 February staff at the care home identified some damage to the skin and a red area on Mr X’s lower back. They applied a barrier cream and had this checked by the district nurse. The nurse advised staff to apply cream to the area, move Mr X every four hours and sit him on a gel cushion to relieve pressure. Records show staff did this throughout the rest of Mr X’s stay.
21. On 25 February the care home provided Mr X with an air flow air mattress to help ease pressure on his sore area while he slept.
22. In the early hours of 26 February, notes show Mr X’s room was very hot which meant he had sweat a lot. Staff fully changed Mr X and his bed, and recorded he was a bit disorientated before going straight back to sleep and appearing settled.
23. Notes show that in the afternoon of 26 February Mr X could not stand even with the help of four staff and so they used a hoist. The care home did not call Mrs X to let her know Mr X’s mobility had changed and the notes do not show what action the care home took to address this.
24. Mr X was due to leave the care home on 28 February but the records from that day show the Care Provider decided it was not appropriate because:
• Mr X needed to be repositioned every two hours during the day and every four hours at night because of the sore area on his lower back.
• The mattress Mr X had at home was no longer suitable for his needs and may prevent the sore area from healing.
• Mr X’s mobility was now extremely poor, and he needed use of a hoist.
• Mr X’s swallowing had deteriorated to the point where he needed a pureed diet.
• Mr X had stated clearly to care home staff that he did not want to go home.
25. The Care Provider made an urgent request for a district nurse to assess whether it was achievable for Mr X go home and for a Speech and Language Therapy (SALT) assessment. The district nurse reported to social services that Mr X had asked to stay at the care home. The Care Provider also noted Mr X would need a higher-grade mattress for pressure relief and a hoist to help him mobilise.
26. Notes from 1 March show Mr X told staff at the care home he wanted to go home. Physiotherapists who had been working with him agreed to look into getting a hoist and other relevant equipment for when Mr X returned home.
27. In the extra time Mr X was at the care home, all meals were recorded as he had lost weight since he arrived. Not all meals were specifically recorded as being pureed, although the SALT assessment concluded this was necessary.
28. Mr X returned home on 4 March.
29. Mrs X complained to the Care Provider on 30 March. Mrs X explained:
30. She believed the Care Provider had failed to give the right care to Mr X and had tried to turn this around on her.
• She said she did not believe Mr X had said he did not want to come home and the Care Provider had unnecessarily involved social services to prolong his stay.
• She felt the Care Provider wrongly questioned the care she had been providing and could continue to provide to Mr X.
• The Care Provider had failed to identify a UTI Mr X had developed and she did not believe they had been properly monitoring his fluid intake.
• She had told the Care Provider Mr X needed soft food, but once he entered the care home Mrs X had been told he was having to take food from his mouth.
• She was also unhappy the Care Provider had not let her know when it identified Mr X’s mobility deteriorated or arrange for an Occupational Therapist to assess him.
31. Mrs X emailed the Care Provider again the following day to add that a member of staff told her on 28 February they would immediately order a hoist and mattress for Mr X but this did not happen. It was not until the Occupational Therapist placed an order on 2 March that these items were ordered.
32. The Care Provider responded to Mrs X’s complaint on 27 April. It explained:
33. The preadmission checklist, completed with Mrs X, listed Mr X’s food requirements and the kitchen staff were aware of this. It said staff supported Mr X with his meals and his drinks and records show he had soft options every day other than two days where the food was a roast and Mr X had this as a pureed meal. The Care Provider explained the day Mr X had pulled food from his mouth, the choices were cottage pie or an omelette, both soft options.
• It had found Mr X’s mobility to be variable, but he could generally mobilise and walk around. The Care Provider said it was only on 26 February that Mr X could not stand, and it needed to use the hoist from then. It explained Mr X’s inability to stand on 28 February meant it was not safe to transfer him out.
• Staff supported Mr X to drink well during his stay and frequently changed wet incontinence pads which suggested reasonable hydration. Mr X’s temperature was taken regularly and was in a normal range and there were no other signs of a UTI. Although staff noticed reduced mobility on 27 February, this was put down to being the result of a poor night’s sleep when his room was found to be too hot.
• Mrs X was aware Mr X had a red area on his lower back prior to admission. A district nurse attended Mr X on 24 February to apply a dressing and advise staff on what action to take. The Care Provider felt it had responded proactively to the situation to reduce the risk of a pressure sore.
• It did not believe anyone was trying to scare Mrs X, but rather keeping her informed of the care Mr X needed and checking she was able to provide this.
• SALT was contacted to ensure Mr X was receiving the right consistency of food while at the care home to avoid choking and this is normal when a soft option diet is provided. SALT confirmed a pureed diet was appropriate for Mr X.
• The Care Provider did not contact an Occupational Therapist before 28 February as Mr X’s mobility was variable and it had not known him long enough to determine if this was unusual for him.
• It had not tried to keep Mr X any longer than necessary, but it would not have been safe to discharge Mr X on 28 February. Social Services were only contacted to comply with the Care Provider’s safeguarding duties after Mr X expressed a desire not to go home.
• As soon as it was agreed Mr X’s stay would be extended, staff at the care home referred to Occupational Therapy who requested the relevant support and equipment to aid his return home.
34. Mrs X referred her complaint to the Ombudsman in May 2022.
35. In response to our enquiries, the Care Provider has told us:
• From pre-admission it was aware of the foods Mr X liked and could eat. Mr X’s weight was taken on admission and, as this was good, there was no initial monitoring of his food or fluid intake. However, staff did assist with all his meals and drinks as well as prompting him to drink. It explained it only usually monitors food and fluid intake where a resident’s weight has fallen, they are frail, ill, or have a bad appetite. The Care Provider explained it found Mr X’s weight had dropped on 1 March and they monitored his food and fluid from that point.
• District nurses were contacted on 23 February as a red area was detected on Mr X’s back. This resulted in Mr X being moved to a different mattress type and being regularly repositioned.
• Although Mr X’s mobility was unpredictable, it was only from 26 February he required a hoist, and this was put down to an abnormal night’s sleep. The Care Provider explained it is difficult to really assess a change in mobility for a resident it is not familiar with over as short a time as Mr X was with it.
• It noticed the reduction of Mr X’s mobility on 26 and 27 February, which was a weekend, so the GP was closed, and Mr X was due to go home on the Monday. The only other possibility would be to call 111 for advice. As Mrs X was having her first period of respite care in a long time, the Care Provider did not want to disturb her, but it is sorry it did not contact her at that time.
• It feels it contacted medical professionals in a timely manner as soon as the weekend was over and services reopened on the Monday.
• There were no signs of a UTI while Mr X was with the care home. The only exception being when Mr X was hot in the night of 26 February but this was put down to his room being too hot and he continued to pass urine well from then.
• Nobody criticised the care Mrs X had given to Mr X and staff actually praised how well she had managed but said she may need extra support. The Care Provider also said nobody was trying to scare Mrs X into leaving Mr X at the care home, they were trying to ensure she understood Mr X’s needs at that point.
• When it became clear Mr X could not go home on 28 February the relevant medical professionals were called for assessment. Social services were also contacted to comply with the Care Provider’s safeguarding duties when he expressed he did not want to return home.
36. The Care Provider also provided a witness statement from a member of staff who was present on 28 February. They confirmed Mr X said twice that he did not want to go home.
37. In response to a draft decision, Mrs X said:
• Negligent care was the reason Mr X had to spend a further five days at the care home.
• When Mr X returned home, a further SALT assessment recommended he return to a diet of soft food rather than pureed.
• Despite it being a weekend, the Care Provider should have contacted a doctor when it noticed a change in Mr X’s mobility.
• The Care Provider did not order equipment to facilitate Mr X’s return home when it said it would.
• During a visit, she observed Mr X was given a drink but nobody checked to make sure he was actually drinking.
• The Care Provider incorrectly told a district nurse that Mr X had full mental capacity to make decisions for himself.
• Social services agreed there was no issue with the care she had been providing.
• It took two weeks to get Mr X back on his feet which meant Mrs X had to pay more money for help from a care agency.
38. The Care Provider said:
• There is no obligation to monitor food and fluid intake unless there is a specific reason to as people should have a choice in what to eat and how much.
• It does not routinely monitor food and fluid intake. Where staff had noted this prior to 1 March 2022, they were exceeding expectation.
• It feels it complied properly with Regulations 14 and 17.
• It is difficult to get medical advice on the weekend and it believes the advice would have been to monitor Mr X, which is what it did. It felt it would have been inappropriate to disturb Mrs X during her break to inform her of this.
39. Neither Mrs X not the Care Provider have provided new information in their communications so my findings remain the same.

Analysis

Level of care Mr X received

40. It must have been distressing for Mrs X to see Mr X’s deterioration following his stay at the care home, however I cannot say this was a direct result of the care he received. I need to give the appropriate weight to the documentary evidence available to decide whether there is evidence of fault by the care home.
41. The care notes suggest staff at the care home consistently checked on Mr X to ensure he was comfortable, clean, and well. They show staff helped Mr X to use the toilet and frequently changed his incontinence pads as well as helping him to dress and maintain his personal hygiene. They also show staff ensured Mr X was taking his medicine correctly and sought guidance when they identified a sore area on his back. The notes appear to show staff at the care home provided Mr X with constant care while he was there.
42. The Care Provider has explained it does not monitor how much residents are consuming unless there is good reason to keep an eye on this. Because of this, it did not monitor how much Mr X was eating and drinking until it noticed his weight had dropped on 1 March. However, Regulation 14 of CQC guidance says nutritional and hydration intake should be recorded. Failure to do so is fault.
43. The Care Provider has said staff assisted Mr X with all his meals and drinks, but this is not fully reflected in the care notes provided. Prior to 1 March, the notes only seem to sporadically record staff assisting Mr X with his meals and drinks. As Mr X’s pre-admission forms specified he required assistance with food and drinks, the Care Provider should have ensured its records reflected that this took place. Failure to do so is fault and not in line with Regulation 17 or 14 of CQC guidance. That said, a lack of records is not evidence of fault in the care given, so the injustice to Mrs X is uncertainty here.
44. Mrs X has also said the Care Provider ought to have detected a UTI Mr X developed during his stay. I appreciate Mrs X feels strongly this would explain Mr X’s deteriorating mobility, but there are too many variables for me to be able to say this occurred during his stay at the care home or that it should have been identified. The staff were constantly monitoring Mr X and ensuring he was passing urine correctly so I could not say, even on the balance of probabilities, they were at fault for failing to detect a UTI.
45. I do not find there is evidence of fault with the care given to Mr X.
46. I appreciate Mrs X feels very strongly that the care home did not provide adequate care to Mr X but the notes do not reflect this. Even when considering the gaps in the records, I have seen no evidence of fault in the care provided.

Failure to contact Mrs X and health professionals

47. The care notes show the Care Provider contacted relevant health professionals, such as district nurses, when it needed guidance on how to care for Mr X. I do not find fault with the Care Provider here.
48. The Care Provider has explained it did not contact a GP when it noticed Mr X’s mobility had decreased on 26 February as this was a weekend and they would not be open until Monday – the day Mr X was due to return home. The Care Provider has explained it did not take any further action at that point because it attributed Mr X’s change in behaviour to a restless night’s sleep where his room was too hot. I appreciate this is frustrating for Mrs X, but I do not find fault with the Care Provider’s decision making here.
49. However, in line with Regulation 9 of the CQC guidance, the Care Provider ought to have sought Mrs X’s views. Failure to do so, even because the Care Provider did not want to disturb Mrs X’s break, is fault. Had the Care Provider discussed Mr X’s change in behaviour with Mrs X at this stage, it is possible she would have directed it to seek emergency action, such as contacting 111 for advice. This is injustice as it has caused further uncertainty for Mrs X.

Criticism of Mrs X and extending Mr X’s stay

50. When considering complaints, if there is a conflict of testimony or evidence, we make findings based on the balance of probabilities. This means weighing up the available relevant evidence and basing our findings on what we think is more likely to have happened. Sometimes it is not possible to come to a finding, even on the balance of probabilities, where there is no independent evidence and both sides have differing views on the same events.
51. Mrs X has said she feels very strongly that the Care Provider was unfairly critical of the care she had been providing Mr X. She also says staff tried to scare her into leaving Mr X at the care home for longer than planned.
52. The Care Provider denies this was the case and says staff believed she had managed very well. The Care Provider says staff were trying to support Mrs X and make sure she was fully prepared for Mr X to return home.
53. There are no physical records to support either side’s version of events. I cannot know, even on the balance of probabilities, what was said to Mrs X or what the staff’s intentions were. For this reason, I could not find the Care Provider to be at fault here.

Giving wrong information to district nurses and social services

54. While Mrs X feels strongly Mr X would not have said he did not want to go home, the Care Provider has produced a witness statement from someone who was present at the time confirming he said this at least twice.
55. Under CQC Regulation 13, the Care Provider is obliged to report safeguarding concerns when they arise and this is why it informed the district nurse and social services it had concerns about Mr X returning home. I do not find fault with the Care Provider here.
56. That is not to question the care Mrs X was providing Mr X at home, simply to say the Care Provider was not at fault for raising concerns once they came up.

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Agreed action

57. To remedy the injustice set out above, I recommended the Care Provider, within one month of our final decision:
• Provide Mrs X with a written apology for failing to keep full records relating to Mr X’s care and for failing to contact her when it noticed a change in Mr X’s behaviour.
• Pay Mrs X £200 to recognise the uncertainty and distress she would have been caused by the failure to alert her to the change in Mr X’s behaviour and to keep her involved in Mr X’s care.
• Remind staff of the importance of keeping accurate, complete, and contemporaneous notes throughout a resident’s care and provide the Ombudsman with evidence of this.
• Remind staff of the importance of giving residents or their representatives the opportunity to comment or object to decisions that are made about medical attention required during their stay and provide the Ombudsman with evidence of this.
58. The Care Provider has agreed to these recommendations.

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Final decision

59. I find the Care Provider at fault for failing to take and keep complete notes and records. I also find the Care Provider at fault for failing to give Mrs X an opportunity to comment on its decision not to seek medical attention for Mr X following his change in behaviour.
60. I do not find fault with the level of care Mr X was provided, with the way the Care Provider discussed the care Mrs X had provided, or the decision to consult social services.
61. The Care Provider agreed with my recommendations and I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman