Summary: Ms X complains about poor care provided to her father, Mr Y, whilst at a Council commissioned care home. We have found fault by the Council causing an injustice to Ms X. The Council has already produced an action plan to address the faults identified in this statement. The Council has agreed to apologise and make a symbolic payment for the distress caused to Ms X.

The complaint

1. Ms X complains about poor care provided to her father, Mr Y, whilst at a Council commissioned care home, Ings Grove House. Ms X complains about:

1. poor communication between professionals;
2. poor communication at handovers;
3. Mr Y’s charts being completed and signed retrospectively or only partially completed;
4. poor administrative communication both before and after Mr Y’s death;
5. inadequate assessment of Mr Y’s need for pain relief throughout;
6. mismanagement of catheter care;
7. failure to complete medication administration records for Mr Y’s ointment;
8. no clear complaints procedure;
9. poor patient handling techniques;
10. poor pressure sore identification and prevention;
11. negligence in not meeting Mr Y’s basic care needs; and
12. inaccurate feedback to family on Mr Y’s progress during his stay.

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The Ombudsman’s role and powers

2. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)
3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
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)
6. 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

7. I considered the information provided by Ms X and discussed the complaint with her. I made enquiries of the Council because it commissioned Mr Y’s care. I considered the information provided in response to those enquiries.
8. Ms X and the Council had the opportunity to comment on my draft decision. I considered all comments before making a final decision.

Scope of investigation

9. The Council completed an investigation into Ms X’s complaint and upheld the following:

• poor communication between professionals;
• poor communication at handovers;
• patient charts being completed and signed retrospectively or only partially completed;
• poor administrative communication both before and after Mr Y’s death;
• inadequate assessment of Mr Y’s needs for pain relief throughout;
• mismanagement of catheter care;
• failure to complete medication administration record for Mr Y’s ointment;
• Mr Y’s deterioration was not discussed soon enough; and
• no clear complaints procedure.

10. I do not intend to investigate these issues as the Council has already accepted fault. I will however consider whether these faults have caused an injustice to Mr Y and/or Ms X

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What I found

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC is the statutory regulator of care services. It keeps a register of care providers that 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.
12. Regulation 9 of the Health and Social Care Act 2008 says the care and treatment of service users must be appropriate, meet their needs, and reflect their preferences.
13. Regulation 12 sets out the requirement for care and treatment to be provided in a safe way for service users. This says a registered person must, amongst other requirements, do the following:
• assess the risks to the health and safety of service users receiving the care or treatment;
• plan and deliver care based on risk assessments which balance the needs and safety of service users with their rights and preferences;
• do all that is reasonably practicable to mitigate risks;
• respond appropriately and in good time to people’s changing needs;
• administer medicines accurately, in accordance with any prescriber instructions and at suitable times to make sure that people are not placed at risk.
14. Regulation 17 says providers must, “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”.
15. Providers must ensure that records relating to the care and treatment of its service users are: “… complete, legible, indelible, accurate and up to date, with no undue delays in adding and filing information, as far as is reasonable”.

Support and service provision

16. Ings Grove House (the care home) is an intermediate care unit which is facilitated by both health and social care staff. The Council provide the social care element of support which includes day and night care support staff. These staff were responsible for providing and supporting Mr Y with his personal care; movement and handling and dietary and nutritional needs. The care staff were responsible for reporting any concerns identified with Mr Y’s health care to a member of the health care team.
17. The Council’s team co-ordinators lead and support the care staff on shift as well as support with any medication needs required including administration of prescribed medication. The Council’s deputy managers oversee and address any shift concerns or requirements. In this respect, the Council was responsible for Mr Y’s admission into the care home, administration of prescribed medication and ensuring relevant information about Mr Y’s clinical care and support needs were shared with the health team. The Council would take instruction from the pharmacy and GP regarding the prescribed medication, dosage or changes to Mr Y’s medication.
18. The Council also commissioned a care agency which was used during the period of Mr Y’s stay at the care home to cover staff absence and to support the team to ensure they had safe and adequate staffing levels.
19. The health care team provide rehabilitation support at the care home. The nurses liaise with the medical team when required.

What happened

20. This report contains a brief chronology of key events. It is not meant to detail everything that happened.
21. Mr Y entered the care home on 6 January 2023. The Council assessed Mr Y on admission, completed several risk assessments and put in place several care plans to meet Mr Y’s needs. It was recorded that Mr Y had poor mobility since discharge from hospital and therefore at risk of falls. Mr Y was on limited fluids of one litre per day. Mr Y’s skin showed no broken areas but some red areas where the catheter tube rested. The pre-assessment included a list of Mr Y’s current medication.
22. The care home also completed several risk assessments including moving and handling, falls risk, malnutrition universal screening tool (MUST), waterlow and fluid intake. Other risk assessments were completed but I have only referenced those relevant to this investigation.
23. On 31 January, Mr Y moved to another care home. Sadly, Mr Y passed away on 1 February.

Analysis

Pain management and relief

24. Ms X said the care home were aware of the significant pain her father endured when trying to stand, walk and later when moving in bed. Ms X said the care home failed to provide this feedback to the GP nor did it request the locum GP to prescribe more effective and stronger pain relief.
25. When Mr Y entered the care home, he was prescribed one or two 500mg paracetamol to be taken up to four times per day. Mr Y was also prescribed capsaicin cream to be applied four times per day for his bilateral knee pain.
26. On 11 January, Mr Y was supported with physiotherapy. Mr Y reported pain in his knee and asked to rest in a wheelchair. The record states, after a short rest Mr Y was able to continue to mobilise and transfer independently. Mr Y returned to his bedroom and staff noted that he was fatigued and required rest but happy sitting in his chair. The physiotherapist recommended the increased knee pain should be monitored.
27. On 14 January, Mr Y refused physiotherapy as he was not feeling up to it. Mr Y’s son felt that his father’s mobility had deteriorated and requested a visit from an out of hours GP. The GP visited Mr Y and made no changes to his pain relief medication.
28. The next day, Mr Y agreed to physiotherapy. Mr Y’s son was present. The records stated that Mr Y did well, and the knee pain seemed to ease with movement.
29. On 17 January, Mr Y reported knee pain when walking with the zimmer frame. The physiotherapist agreed to speak to a nurse about applying pain relief gel to Mr Y’s knee before physiotherapy. Mr Y was also fatigued after walking approximately eight metres with a short rest.
30. On 20 January, Mr Y was able to stand but could not walk due to feeling breathless and tired. Mr Y said he felt “too unsteady”.
31. On 23 January, it is recorded that Mr Y had reduced mobility, his knees were creaky, and he could transfer with the assistance of one carer. Mr Y was reported as being quite breathless at times.
32. On 24 January, an occupational therapist reported that Mr Y could not extend his knees or stand up straight. The record stated Mr Y was “crying out in pain” due to pain in his knees. The therapist said she would request a GP to review Mr Y. Mr Y asked for cream to be applied to his knee. The health team also advised care staff that they may need to consider hoisting Mr Y.
33. The records show that staff gave Mr Y two paracetamol in the morning and late afternoon. Ms X said staff only administered half a paracetamol to her father in the evening. The medication records do not support Ms X’s view. However, it is noted that Mr Y did not receive any other pain relief that day.
34. On the same day, in the evening two therapists supported Mr Y to stand. Mr Y expressed feeling a lot of pain. Mr Y struggled to move his feet and said he was in pain all over. The care staff provided full assistance with Mr Y’s nighttime care. Mr Y continued to report extreme pain, he was fatigued and breathless.
35. On 25 January, a nurse recorded that Mr Y was only receiving paracetamol twice daily and capsaicin cream to both knees twice a day. The nurse requested a review of Mr Y’s pain relief medication and prescription for the cream.
36. On the same day, the GP prescribed codeine, to be administered four times per day for pain relief. The next day staff gave Mr Y codeine four times per day. From 27 January to 30 January staff gave Mr Y codeine three times per day.
37. On 27 January, Mr Y’s mobility and exercise care plan was suspended due to staffing issues. The record also stated the plan was no longer appropriate as Mr Y required a full body hoist and his mobility had deteriorated.
38. On 30 January, the GP reviewed Mr Y. Ms X was present for the review. The GP prescribed palliative care medication for Mr Y and stopped codeine. The GP recorded that Mr Y appeared comfortable and not in any pain. Mr Y also reported that he was pain free.
39. The Council has already acknowledged there was an inadequate assessment of Mr Y’s needs for pain relief throughout his stay at the care home. The records show that paracetamol and capsaicin cream was not consistently administered as prescribed. This is fault. I also find that staff failed to administer Codeine as prescribed by the GP. This is further fault and a potential breach of regulation 12.
40. Overall, I find whilst there is evidence Mr Y did receive some pain relief, medication was not administered as prescribed. On balance, I consider there was times when Mr Y was in pain and did not receive pain relief he needed. Mr Y was encouraged and supported to stand and walk without adequate pain relief. Whilst it is difficult to know the impact of the failures on Mr Y at the time, the lack of pain relief would have added to his level of pain and distress.
41. I have found no evidence to suggest staff did not seek advice from the GP when Mr Y complained of increased pain and when he showed signs of deterioration. I also do not find the care home at fault for not administering codeine from 30 January as this was a decision made by the GP.

Pre-admission assessment – bruising

42. The Council’s complaint response said, nursing records showed Mr Y had bruising on admission. Ms X said her father had no bruising when he entered the care home. Ms X said she identified bruising on her father’s upper right arm on 24 January.
43. In response to our enquiries the Council has confirmed that bruising was not present on admission to the care home. The Council said the bruising was identified by a nurse on 25 January. I have checked the records which stated, “please do [blood pressure] on left arm…has intensive bruising right arm”.

The Council has stated the electronic system pulled this information back through the records every time the care plan was completed. Therefore, it appeared the bruising was present on admission. I find fault with the care home’s record keeping and this is a potential breach of regulation 17.

Moving and handling

44. Ms X said she witnessed inadequate and unsafe patient handling procedures on three consecutive evenings.
45. On 24 January, two therapists supported Mr Y to stand. Mr Y expressed feeling a lot of pain. Mr Y struggled to move his feet and said he was in pain all over. The record stated the therapists positioned the bed behind Mr Y and he was assisted to transfer to bed. Ms X was present at the time and says her father was inappropriately manoeuvred around the bed using his trouser waistband to prevent a fall. Ms X said she had to help prevent her father from falling whilst a carer ran to fetch the commode from another room.
46. In response to our enquiries the Council said the therapist assisted Mr Y to bed using his waistband to prevent him from falling and there was no time to find alternative equipment. Following this incident, the therapist advised that Mr Y should be hoisted, and personal care provided on the bed to maintain his safety.
47. As I was not present it is difficult to say now whether what Ms X witnessed was poor practice. However, given the nature of Mr Y’s sudden difficulties in standing, I am satisfied that on balance the carers took appropriate action to prevent Mr Y from falling at the time. However, the lack of records about this incident is fault and a potential breach of regulation 17.
48. The next day, two carers supported Mr Y to bed. Ms X said the carers held her father up by holding his arms and shoulders. Ms X said her father was not wearing any trousers or underwear. The carers then encouraged her father to try and pull himself up onto a rota stand from a low-level commode chair. Ms X said the carers eventually used a hoist after several attempts to pull her father around the bed had failed.
49. I have reviewed the care records and cannot find any notes regarding this incident. As part of its investigation into Ms X’s complaint the care home interviewed both care staff. The carers said they were not aware that Mr Y required hoisting. Mr Y lost his balance and Ms X helped to support him while one of them went to fetch the commode. The carers stated that Mr Y was supported with changing his pyjamas while sitting on the bed and was not fully undressed.
50. I find the care home to be at fault in failing to ensure staff were aware of Mr Y’s deteriorating mobility and that he should be hoisted at all times. As a result, Mr Y was left at risk and his safety was compromised. This is a potential breach of regulation 12. The lack of records is also fault and a potential breach of regulation 17. Council’s complaint response accepted there had been poor communication at staff handovers.
51. On 26 January, Ms X said she found her father perched on the edge of his chair looking distressed, his pyjama bottoms were around his knees with one carer trying to get him to stand and pull him out of the chair. There are no records available for me to determine what happened here and as I was not present it is difficult to say now whether what Ms X witnessed was poor practice. I therefore cannot pursue this part of the complaint further. However, the lack of records is fault and a potential breach of regulation 17.

Repositioning

52. Ms X said she had to frequently prompt moving and repositioning and turning once her father was unable to get out of bed. Ms X referred to a specific incident on 28 January. She said her father had been in bed all morning and she suggested staff should reposition him and check all his pressure areas. Ms X said staff reassured her that all pressure areas had been checked and were okay. Ms X said the next day both her father’s heels showed signs of developing pressure sores.
53. The records show a review of Mr Y’s skin integrity was completed on 27 January, and no concerns were identified. The nurse recommended repositioning every three hours. However, the Council has confirmed there is no evidence that this was handed over to care staff.
54. On 29 January, the care home implemented a repositioning chart which stated Mr Y required repositioning every two hours. However, Mr Y was not repositioned from 8:00pm to 8:00am the following day. A nurse also identified a pressure sore on Mr Y’s heel and provided a heel wedge for support.
55. The next day, Mr Y was not repositioned between 4:00pm and 2:00am the following day. On 31 January, Mr Y was not repositioned for four hours.
56. The evidence shows that Mr Y was not moved, turned or repositioned in accordance with his needs and therefore did not receive adequate pressure relieving care which may have affected his skin integrity. This was fault and is a potential breach of regulation 17. It is difficult to know the impact of the failures on Mr Y at the time. However, the faults have caused Ms X distress and uncertainty that her father did not receive the care he should have.
57. Ms X also said staff completed the repositioning chart retrospectively. In response to our enquiries the care home confirmed this was correct. The chart was implemented on the afternoon of 29 January and care staff had documented retrospectively that they had repositioned Mr Y at 8:00am and 10:00am that day. This is fault and has added to Ms X’s distress and uncertainty that her father did not receive the care he should have.

Home visit

58. Ms X said on 24 January her father was left sitting in a room wearing an outside down coat and fleece for at least six hours following a cancelled planned home visit. Ms X said her father fell asleep in the chair and staff failed to realise he had overheated in his jacket, did not give him any food or drinks and did not try and establish why he was drowsy.
59. The care home has acknowledged this was not best practice. The staff member on duty could not recall whether Mr Y was wearing a coat and because I was not present, I cannot make any finding on this aspect of Ms X’s complaint. The care home said Mr Y was offered fluids during the day but the fluid chart for 24 January was missing. This is fault and a potential breach of regulation 17. The lack of records has caused Ms X distress and uncertainty about whether her father was provided with adequate nutrition and fluids.

Fluid intake and monitoring

60. Ms X says her father should have been on strict fluid restrictions with monitoring of fluid intake and urine output throughout his stay.
61. The care home implemented a fluid monitoring chart from 8 January, for the purpose of recording Mr Y’s fluid intake and output. Mr Y was on restricted fluids of 1 litre per day. The care home has acknowledged the charts have not been completed consistently and there are gaps in the records. This is fault and is a potential breach of regulation 17. I cannot say what impact this had on Mr Y’s health and wellbeing, but the faults have caused Ms X distress and uncertainty that her father did not receive the care he should have.

Communication with Mr Y’s family

62. Ms X said the care home provided inaccurate feedback to the family on her father’s progress during his stay. She says staff told the family Mr Y was progressing and becoming more mobile and he was walking to the toilet unaided. Ms X said this was not true, and her father’s health was declining.
63. The records show Mr Y showed signs of fatigue on 13 January and his mobility started to decline from this point. The care home has acknowledged there was a lack of communication between the care staff and health team about Mr Y’s deterioration. This was fault which resulted in the family being misinformed. The Council’s complaint response upheld Ms X’s complaint about poor communication between professionals, poor administrative communication both before and after Mr Y passed away and failure to discuss Mr Y’s deterioration sooner.

Injustice and remedy

64. The concerns raised by Ms X about Ings Grove House have been investigated by the care home and the Council. This has resulted in an action plan to improve the service delivered to other residents. From these investigations we know there were many times when Mr Y did not receive the care he needed. This is not disputed by the Council and it upheld aspects of the complaint as detailed in paragraph 10.
65. The care that Mr Y received fell significantly below that which he was entitled to expect. This was fault which caused him an injustice. Rather than receive the care to which he was entitled, and which should have limited the risks to him, he was put at an increased risk of harm in relation to inadequate pain relief, inconsistent repositioning and fluid monitoring, poor catheter care and poor record keeping. I cannot say the deterioration in Mr Y’s health was a result of poor care, but it would have caused avoidable distress and discomfort to Mr Y.
66. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of, for example, the impact of poor care that person might have received while they were alive. This is because the person who received the poor care cannot benefit from such a payment. Mr Y has now sadly passed away and therefore it is not possible for the Ombudsman to remedy any injustice caused to him.
67. However, if we consider the person who has complained to us has been adversely affected by the impact of that poor care on their relative, we may make a recommendation to remedy their own distress.
68. In my view, the faults identified in this statement in addition to those accepted by the Council in its complaint response have caused Ms X significant distress and uncertainty. Ms X had to regularly liaise with the care home and the Council about her concerns. This created avoidable time and trouble.

Service improvements

69. The Council and care home have already introduced a service improvement plan to address areas of concern as a result of Ms X’s complaint. The action plan focusses on improving communication between teams, management of deteriorating patients, review of medication process, falls prevention, moving and handling techniques, staff handover, pressure sore management, record keeping and complaint handling. The Council has confirmed that regular meetings are held with team managers and team leaders to track and evidence progress with the action plan, improvement and learning. We welcome this approach by the Council.
70. The Council has also introduced a new online system to prevent records being completed retrospectively. The system allows the manager to track any late care interventions through alerts. The staff will also receive an alert to remind them that an intervention is required for a resident. I appreciate that Ms X may think this does not go far enough in addressing concerns around records being completed and signed retrospectively or only partially completed, however, I am satisfied that the new system and action plan are appropriate actions to ensure similar issues in the future do not arise.

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Agreed action

71. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the service of the care home, the following actions are against the Council.
72. Within one month of my final decision the Council should apologise to Ms X and make a symbolic payment of £300 for the injustice caused to her.
73. I acknowledge the Council had already identified several service improvements. It is not necessary for me to make any further service improvements. Within two months of my final decision the Council should send the Ombudsman evidence of its progress with the action plan.
74. The Council should provide us with evidence it has complied with the above actions.

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Final decision

75. I have found fault by the Council causing an injustice to Ms X. I have completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman