Summary: Mrs X complained the care provider failed to provide adequate care and support to her late mother Mrs Y. The care provider was at fault for poor record keeping relating to Mrs Y’s meals and dental care, for failing to follow up attempts to take a urine test and for significant delay in responding to Mrs X’s complaint. The care provider should apologise, make a symbolic payment to Mrs X, and provide evidence of the action it has taken to improve its service.

The complaint

1. Mrs X complained the care provider failed to provide appropriate care and support to her late mother, Mrs Y at Sutton Rose Care Home. Mrs X says the care provider:
1. gave the family inaccurate information about how it would address concerns about Mrs Y’s health;
2. failed to act in response to health concerns raised by the family and delayed obtaining medication for Mrs Y;
3. failed to communicate effectively with the family; and
4. did not provide appropriate general care to Mrs Y, including matters relating to food and dental 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 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 cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended). Mrs X complained to us in June 2023. I considered matters back to May 2022 because of delays in the care home’s response to the complaint.
4. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
5. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
6. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:
• their personal representative (if they have one), or
• someone we consider to be suitable. (Local Government Act 1974, section 26A(2), as amended)
7. 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)
8. 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

9. I considered information Mrs X provided, including notes of a telephone conversation with her.
10. I considered the care provider’s response to our enquiries and the relevant law and guidance.
11. Mrs X and the care provider had the opportunity to comment on a draft of this decision. I considered the comments I received before making a final decision.

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What I found

12. 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. The standards include:
• providers must make sure each person receives appropriate person-centred care and treatment based on an assessment of their needs and preferences (regulation 9).
• providers must make sure that people who use their services have adequate nutrition and hydration to aid good health. People must be provided with appropriate food and drink and any support they may need to achieve adequate nutrition (regulation 14); and
• providers must securely maintain accurate, complete and detailed records about each person using their service (regulation 17).

Care home complaint policy

13. The care home has a complaints policy. It says its investigations should not take longer than 28 days unless a different timescale is agreed with the complainant.

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What happened

14. The information below is not a comprehensive overview of everything that happened. It is a summary of key information.
15. In early 2022 Mrs Y was admitted to hospital because of a urinary tract infection (UTI). Following an assessment by the local council, Mrs Y was moved to an initial care home. The family moved Mrs Y to Sutton Rose Care Home in mid-May 2022, which is part of the same care home group. Mrs Y’s family privately funded the arrangement.
16. The care home referred Mrs Y to physiotherapy. The records show the physiotherapist attended the care home the week after she moved in and recommended Mrs Y could sit on the edge of the bed and could sit in a chair for one hour a day. The physiotherapist said Mrs Y should not weight bear and should be moved using a hoist and the support of two staff.
17. In early June 2022 Mrs Y’s care plan was updated. This included information about how Mrs Y had a “reduced appetite and need plenty of prompting and encouragement” to eat, but that “I am able to eat independently”. The records show staff monitored Mrs Y’s food and fluid intake and staff should ensure Mrs Y had adequate fluids throughout the day to prevent a urine infection from developing. Mrs Y was also prescribed fortified drinks.
18. The care plan noted Mrs Y was doubly incontinent, and staff should observe Mrs Y for any odour or changes in urine colour. If concerned, it noted her urine should be tested and the GP contacted.
19. It noted Mrs Y required supervision and support from two staff members with personal cleansing, dressing and undressing and full support with her oral hygiene.
20. In early June 2022 a family member wrote to the care home to raise concerns about Mrs Y’s care. These concerns included a lack of support at mealtimes. They noted that when visiting Mrs Y, they found her asleep with a tray on the bed with a cold meal on it. They said Mrs Y required more stimulation during the day such as the television being switched on. They wanted Mrs Y to be motivated more and able to transfer to a wheelchair. Another relative sent an email around the same time that when they visited Mrs Y was wearing a jumper covered in dried-on food which appeared to be breakfast cereal. They were concerned she had not been changed.
21. The care provider agreed to arrange a meeting with the family to discuss their concerns. Mrs X says during the meeting the family asked what action the care home would take if Mrs Y had a suspected UTI. Mrs X says the care home told her it would simply administer antibiotics without testing Mrs Y. This discussion is not included in the notes of the meeting.
22. The notes of the meeting referred to issues including food encouragement, stimulation, Mrs Y’s call bell not being in reach, a request for physiotherapy and Mrs Y not receiving her eye medication.
23. Following concerns raised by the family about Mrs Y’s hygiene and appearance, staff arranged for Mrs Y to have her hair done at the care home’s hair salon which family took her to. Following this a relative updated the care home that Mrs Y’s reclining day chair which was used to transport her to the hair salon could not get close enough to the sink so Mrs Y’s hair was washed over a plastic basin. They said Mrs Y found this confusing and upsetting. The relative asked the care home to prioritise Mrs Y’s transfer to a wheelchair so she could have a shower and have her hair washed on a weekly basis. The care home manager said they had ordered a recliner shower chair so Mrs Y could have her hair washed more comfortably. They noted there was an issue with the height of the sink in the salon, but said there was an inflatable hair wash basin at the salon which could have been used. Mrs Y says the family purchased an inflatable basin which was kept in Mrs Y’s room.
24. In late June 2022 the care staff referred Mrs Y to the GP due to her not meeting her fluid target (the amount she was expected to drink) for three days in succession. The GP reviewed Mrs Y. They found she was severely frail with a low body weight. She was settled with no signs of discomfort and there was no indication of dehydration. They considered an average daily intake of 900mls to be sufficient but staff should ensure a high nutritional content.
25. In mid-July 2022, Mrs Y’s family emailed the care home and raised concerns Mrs Y may have a urine infection as she was showing signs of the psychosis similar to when she had a urine infection earlier in the year. They said they had visited to wash her hair but Mrs Y had refused this and become agitated. The family felt she may need some antibiotics.
26. The following day the family member emailed again to report that a visitor had been present when a nurse visited to give Mrs Y a tablet. As soon as the nurse left the visitor saw Mrs Y try and spit the tablet into a tissue. The visitor distracted her and persuaded her to take the tablet.
27. The care home manager responded and said they had spoken with nurse who said they had stayed in the room whilst Mrs Y took her tablets and it appeared she had swallowed them. The manager asked that in future if anything unusual happens, the family report it to the nurse on shift as emails may not be seen on time. The manager also said the nurse would change the care plan to reflect that the person administering the medication should stay longer and ensure Mrs Y took her medication. The records show the care plan was amended.
28. Four days after the family’s initial contact a staff member noted Mrs Y was agitated. They noted in the records that a relative said Mrs Y needed a urine test and they had informed the nurse on duty. That evening, a nurse recorded in the case notes that Mrs Y appeared settled. ‘Daughter concerned may have urine infection due to confusion. Newcastle pad [a special pad used to collect urine samples] put in place to rule out UTI [a urinary tract infection], no other concerns’. The nurse attempted to test the pad but the first pad was dry and the second was soiled. The note recorded they applied a new pad the next morning. Again, the pad could not be tested as it was soiled. The notes show they applied a new pad. There are no records to show it was tested.
29. The care records show Mrs Y’s pad was checked and changed frequently. The notes make no reference to a change in colour or odour of the pad. Mrs Y’s temperature, 10 days after the family’s initial contact about a potential UTI was 37 degrees which is within the normal range. On that same day the notes record the Advanced Nurse Practitioner from the GP surgery reviewed Mrs Y’s medication. They noted poor compliance with one medication and agreed to stopping it.
30. The following day, 11 days after their initial contact, the relative emailed the care home again to ask if Mrs Y was given antibiotics as they noted Mrs Y was struggling to communicate and eat when they visited that day. The manager responded that they had passed the concerns to the nurse. A nurse noted in the care records that evening that Mrs Y appeared well. They noted family had raised concerns, however Mrs Y had refused to have observations carried out. ‘Newcastle pad placed in pad for urine collection to test. Night staff to complete and continue to observe and monitor’. The records show when staff later checked Mrs Y’s pad it was soiled so was changed.
31. The following day Mrs Y’s temperature was again recorded as within the normal range, as was her respiration rate. The notes record Mrs Y remained very frail with a poor food and fluid intake. Staff were continuing to encourage oral intake. Mrs Y was refusing all medication.
32. The next day, family visited and had concerns Mrs Y was unwell. A nurse checked Mrs Y’s observations which showed she had a raised temperature and respiration rate. The nurse contacted the out of hours GP to request antibiotics and gave Mrs Y paracetamol. The care home staff continued to monitor Mrs Y.
33. An out of hours GP visited Mrs Y later that evening and prescribed antibiotics for a suspected chest infection. Mrs Y died the following day. Mrs X says the cause of death was recorded as “old age”.
34. Mrs X later requested a copy of the meeting minutes from June 2022, which the care home sent.

Mrs X’s stage one complaint

35. In late October 2022, Mrs X complained to the care home. Mrs X’s complaints included that the care home:
1. had not supported Mrs Y to stand, did not have enough hoists available to safely move Mrs Y out of bed and had not organised for a physiotherapist to see Mrs Y regularly;
2. did not meet with the family to discuss Mrs Y’s specific needs until two and a half weeks after she arrived at the care home;
3. did not share the minutes of the meeting held with the family in June 2022 and the notes did not reflect everything that was discussed;
4. had not responded to emails and calls from the family about Mrs Y’s care, including not responding to an invitation to a continuing healthcare assessment meeting in June 2022, and emails about the family’s concerns Mrs Y had a UTI in July 2022;
5. had not attended to Mrs Y’s dental care and hair care and the hair dressing salon was not fit for purpose and Mrs Y was unable to use the facilities suitably; and
6. did not ensure Mrs Y had eaten her food.
36. In January 2023, Mrs X wrote to the care home to ask about the status of the complaint. The care home responded four weeks later and apologised for the delay. It said it had to re-allocate the complaint to a new officer. It responded to Mrs X’s complaint in May 2023.
37. In summary, it said:
1. Mrs Y was seen by a physiotherapist in May 2022 who recommended she should only sit upright for up to one hour per day to develop her core strength and should not weight bear so safe transfers required the use of a hoist. She was also referred to the community physiotherapist. The care plan reflected this. Therefore, the care home would only use a hoist and would not support Mrs Y to walk. It said four hoists were available at the time which was sufficient to meet the needs of residents.
2. Mrs Y’s care plan was transferred from the original care home. It was reviewed within 72 hours. The care home said it then reviewed the care plan in mid-June and mid-July 2022. The care home apologised for the delay in contacting Mrs Y’s family to discuss her care and to build up relationships with the family when she first entered the care home.
3. It accepted it had not sent the minutes of the June 2022 meeting promptly. It apologised for the delay and said it would ensure meeting minutes are shared either at the end of meetings or agree a deadline during meetings for the minutes to be shared.
4. The care home said any decisions about prescribing antibiotics would be made by a doctor or advanced nurse practitioner, not general staff at the care home. It apologised if there had been any confusion about the process during the June 2022 meeting. It agreed some emails sent by Mrs Y’s family were not acknowledged but said it had acted in response to the family’s concerns. It said Mrs Y was seen by the advanced nurse practitioner from the GP surgery and her observations were normal. It said nurses tried to obtain a urine sample on two occasions over a two-week period after the family raised concerns, but these had been unsuccessful. It said records showed Mrs Y was treated for a chest infection.
5. When Mrs Y became a resident at the care home, the care home found she became distressed when being washed by staff. It said Mrs Y’s care records showed Mrs Y frequently refused care, and that it had spoken with the family about Mrs Y’s care at the time. Mrs Y’s care plan said her teeth should be brushed and dentures cleaned at night. The care home recorded Mrs Y did not like receiving care from staff and the care records showed Mrs Y was regularly offered oral care, but this was frequently refused. In relation to the hair salon, it found the height of the sink was not fitted correctly. It said it had bought an inflatable basin to remedy the issue and a tilt/ recline shower chair for Mrs Y.
6. The care home said Mrs Y’s care notes showed she was supported with food intake. In addition, Mrs Y’s doctor prescribed fortified drinks, and the care home staff regularly offered soup if Mrs Y had refused her food. The care home also noted Mrs Y had slightly gained weight during her time at the care home.
38. The care home said it would remind staff about the importance of acknowledging email communications and ensuring care records regarding residents’ hair and teeth were recorded in line with personal preferences. It said it developed an action plan with the senior leadership team.
39. Mrs X was dissatisfied with the response and wrote to the care home in late March 2023. The care home replied at stage two of its complaints procedure in mid-May 2023. It considered it had already addressed most of the concerns in its stage one response. It said the care home staff followed professional guidance in relation to the safe moving and handling of Mrs Y. It said it had now introduced a ‘getting to know you’ booklet which was being implemented across the whole group as a point of learning. It said assessments from qualified care home staff, the advanced nurse practitioner and GP did not suspect a urine infection.

Enquiry response

40. In response to our enquiries, the care provider has supplied copies of relevant care records for Mrs Y.
41. The care provider’s records show Mrs Y regularly refused meals or ate very small portions. There were occasions (around one to two mealtimes per week) when no entry was made on the meal chart at a particular mealtime. The records showed Mrs Y was also offered snacks and fortified milkshakes throughout the day.
42. In relation to dental care, the records show during June 2022 that Mrs Y’s teeth were cleaned on 10 days, Mrs Y refused this 5 times and there was no record on the other dates listed. The records show Mrs Y received support with her denture care on most days.
43. The records show Mrs Y received a wash nearly every day and a full bed bath or shower around every three or four days. There were days when she refused support. The records show Mrs Y’s hair was washed three times during her time at the care home.
44. The care provider has confirmed that it has:
• introduced a booklet to record information about a resident, their likes/dislikes, person-centred information and the family’s wishes and concerns;
• added customer service and the importance of record keeping to its company induction; and
• improved the training resources given to new staff about how to use the electronic recording system and improved the quality of its care notes.

Analysis

June 2022 meeting

45. The meeting minutes from June 2022 do not document any discussion about Mrs Y’s predisposition to UTIs, nor do the minutes say how the care home would respond in the event of a suspected UTI.
46. Mrs X and other family members recall discussing antibiotics at the meeting with the care home. Even on the balance of probabilities, I cannot establish exactly was discussed with the family about antibiotics and the circumstances when or of the care home would administer antibiotics without testing. However, the care home accepted fault for the delay in sending Mrs X the meeting minutes which caused her frustration and uncertainty about what actions the care home was taking. The care home apologised for the delay. It said in the future it would provide meeting minutes either immediately following meetings or schedule a later time to share them. These were appropriate actions to remedy the injustice caused by the fault and to ensure the fault does not reoccur in the future.

Communication with Mrs X about Mrs Y’s care & care plan

47. The care home accepted fault for the delay in organising a meeting with Mrs Y’s family to discuss Mrs Y’s needs. The care provider reviewed and updated Mrs Y’s care plan monthly. It also made changes where it recognised these were required such as when Mrs Y was found to be spitting out medication. This was appropriate. The care provider has already revised its procedures and introduced a booklet to record information about the resident, their likes and dislikes and the family’s wishes and concerns. This is appropriate to prevent recurrence of the fault.

Health concerns and medication

48. The family informed the care home in early July 2022 of their concerns that Mrs Y may have a urine infection. The care home accepted fault for failing to respond to the email and apologised.
49. The records show the care home sought to test Mrs Y’s urine in response to the concerns raised by family. The records show these attempts were unsuccessful and were not then followed up. The failure to follow these up or to note that this was unnecessary was fault. However, there is no evidence in the records, besides the changes family noticed in Mrs Y’s behaviour, to support the family’s concerns that Mrs Y may have a urine infection. There are no notes which suggest Mrs Y’s urine was discoloured or strong smelling and the records show Mrs Y did not have a raised temperature during this time. The failure to follow up the attempts to take a urine sample does however leave Mrs X with an enduring sense of uncertainty over whether Mrs Y may have had a urine infection and needed antibiotic treatment sooner.

Mrs Y’s general care

50. The evidence seen shows the care home sought to support Mrs Y at mealtimes, but documented she frequently refused to eat the food offered or ate very small amounts. The care home cannot force a resident to eat if they do not wish to do so. This was not fault.
51. There were instances in the meal logs which were blank. It is therefore difficult to know whether Mrs Y was offered food on those occasions or received food/support from visitors. This was poor record keeping, was not in line with the CQC fundamental standards, and was fault.
52. However, on a balance of probabilities I consider this did not cause Mrs X or Mrs Y an injustice because Mrs Y’s weight was mostly consistent during her time at the care home. The records show staff offered snacks between meals and provided fortified drinks to support her nutritional intake. Mrs X says the family also supported her with snacks.
53. The care provider sought to support Mrs Y’s fluid intake. It monitored her intake and when it had concerns it raised this with the GP. There was no fault in the way the care provider supported Mrs Y’s fluid intake.
54. The records show Mrs Y received regular support with washing. However, Mrs Y’s hair was only washed on three occasions in two and a half months. It is acknowledged that Mrs Y could be resistant to personal care. However, the notes do not show Mrs Y was regularly offered and refused having her hair washed. The failure to ensure Mrs Y’s hair was regularly washed was fault. This caused Mrs X distress and frustration.
55. On one occasion a relative visited Ms Y in the evening and found Mrs Y in a jumper covered with dried on food. The failure to offer to support Mrs Y with changing is fault and impacted upon her dignity.
56. The records show there were occasions when staff did not record whether Mrs Y was offered support with her oral care. This was poor record keeping and was fault. However, the care provider could not force Mrs Y to accept support and as there was no regular pattern to her refusal it was not fault to have not raised this with Mrs Y’s family.

Complaint response

57. Mrs X sent her first complaint in late October 2022. The care home provided its formal response nearly seven months later. This was fault.
58. There was a short delay in the care provider responding to Mrs X at stage two of its complaints procedure. It apologised for this at the time and kept Mrs X updated on progress. The responses did address the main areas of concern Mrs X raised. However, the significant delay in responding at stage one caused Mrs X frustration and uncertainty about whether the care home was acting to address her concerns.
59. The failings in record keeping and the delay in responding to the complaint caused Mrs X distress, frustration and uncertainty. Such injustice cannot generally be remedied by a payment, so we seek a symbolic amount to acknowledge the impact of the fault.

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Agreed action

60. Within one month of the final decision, the care provider has agreed to apologise to Mrs X and pays her £200 to acknowledge the frustration and uncertainty caused by its poor record keeping, its failure to follow up attempts to take a urine sample and the delay in responding to her complaint. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology.
61. Within one month of the final decision the care home has agreed to provide us with evidence of the action it has taken to improve the record keeping of staff.
62. The care provider should provide us with evidence it has complied with the above actions.

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Final decision

63. I have completed my investigation. The care provider was at fault causing injustice which it has agreed to remedy.

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Investigator's decision on behalf of the Ombudsman