Summary: Mr X complained on behalf of a family member, Miss Y, about the quality of care she received at Harts House nursing home. The care provider was at fault for delay in contacting the doctor and poor record keeping. The care provider has already apologised to Mr X. It will apologise to Miss Y and pay her £300 and Mr Y £100 to acknowledge the distress, frustration and uncertainty caused by the faults. It has already put service improvements in place.

The complaint

1. Mr X complained the care home failed to provide adequate care for a family member, Miss Y, at Harts House nursing home between late May 2022 and early December 2022. Mr X said it failed to act on medical problems causing swelling and mobility loss and Miss Y suffered from malnutrition. Mr X also said the Care home lost Miss Y’s medical equipment and personal belongings. Mr X said the family had experienced distress and he would like the care home to admit responsibility and not take payment for Miss Y’s outstanding care home fees.

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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. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. 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)
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. 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)
7. 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

8. I have considered:
• the information Mr X provided and discussed the complaint with him on the telephone;
• the care provider’s comments about the complaint and the supporting documents including records from the care provider in response to my enquiries; and
• relevant law and guidance and our guidance on remedies.
9. Mr X and the care provider had an opportunity to comment on this draft decision. I considered comments received before making a final decision.

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What I found

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 provide fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
• Regulation 9 says providers must make sure each person receives appropriate person-centred care and treatment based on an assessment of their needs and preferences.
• Regulation 14 sets out people must have acceptable nutrition and hydration to aid good health. It states people must be provided with appropriate food and drink and any support they may need to achieve adequate nutrition.
• Regulation 16 states complaints to a provider must be investigated thoroughly and any necessary action taken where failures have been identified.
• Regulation 17 states providers must securely maintain accurate, complete and detailed records about each person using their service.

What happened

11. In mid-May 2022 Miss Y was admitted to hospital following a fall at her home. She was discharged into a care home, Care Home 1, as a respite placement. Miss Y self-funded her care.
12. Miss Y’s pre-admission assessment recorded she had physical health conditions and was frail. Miss Y weighed approximately 60 kilograms. The care provider noted Miss Y did not wear a hearing aid on arrival to Care Home 1 but her hearing was limited. A family member of Miss Y, Mr X, said he found a hearing aid and gave it to Miss Y to wear.
13. Mr X had concerns Miss Y was not registered with a doctor when she first moved into Care Home 1. He said because Miss Y’s stay at Care Home 1 was longer than expected, her existing doctors said Miss Y needed to be registered with a local doctor’s surgery. Five days after Miss Y moved into Care Home 1, it completed a doctors registration form for a local doctor’s surgery.
14. In early June 2022 Mr X told Care Home 1 Miss Y had a swollen foot and asked for it to be elevated on a stool.
15. Between late May 2022 and early July 2022 the care home logged a private physiotherapist, organised by Mr X and an occupational therapist (OT) visited Miss Y. The records showed Miss Y was walking with a zimmer frame with the help of one staff member and she walked 10 metres in late June 2022. The records also showed Miss Y declined to take part in seven physiotherapy sessions in June 2022 and early July 2022.
16. Between late June and early July 2022 several entries were made in Miss Y’s daily care notes about Miss Y’s feet being swollen, being breathless and she had low blood pressure. Miss Y’s doctor advised Care Home 1 to stop Miss Y’s high blood pressure medication, which it did.
17. In early July 2022 Care Home 1 had concerns about Miss Y’s swollen feet and a care worker noted in her daily care records advised ‘to inform the GP’ (doctor). The next day Miss Y’s physiotherapist advised a nurse at Care Home 1 Miss Y’s feet were swollen. The next day Care Home 1 emailed Miss Y’s doctor and said her feet were swollen but were elevated. The next day a nurse from the doctor’s surgery called Care Home 1 and Care Home 1 explained Miss Y was vomiting. Miss Y was admitted to hospital in an ambulance where she stayed for 20 days.
18. The care provider said it investigated the delay in contacting the doctor by holding interviews with relevant staff but said the home was also using agency staff and it was ‘unable to fully ascertain why this was not followed up in a timely manner’.
19. In hospital, Miss Y was diagnosed with oedema, which is a build up of fluid causing swelling. Miss Y dropped over eight kilograms of weight in hospital and weighed approximately 49 kilograms on return to Care Home 1. On discharge from hospital the outpatient plan sent to Miss Y’s surgery said ‘GP to consider restarting oedema medicine in one week as was held due to declining renal function. Virtual GP to review bloods in one week’s time to monitor renal function.’ The Care Home 1 records did not say if or when this blood test was taken. Records show Miss Y went back on the oedema medication.
20. When Miss Y was in hospital Mr X told Care Home 1 her hearing aid was missing and should be replaced. Miss Y’s inventory log included clothing, footwear, glasses, one watch alarm and one pendant alarm.
21. In late July 2022 when Miss Y had been discharged from hospital Care Home 1 records showed a physiotherapist continued to visit Miss Y until late August 2022 but Miss Y declined to walk due to tiredness and pain.
22. In early September 2022 the records show Care Home 1 called a blood test team to ask why a visit had not taken place. Care Home 1 said the blood test team did take a blood sample but it did not record when this was carried out.
23. In early September 2022 Miss Y attended a hearing appointment and was given a hearing aid.
24. In late September 2022 and early October 2022 Miss Y’s daily care records showed she started to refuse food or only ate small spoonful’s of food offered and had a reduced fluid intake on some days below 1000 millilitres. In late September 2022 Care Home 1 called an ambulance for Miss Y because of fluid retention concerns and a poor appetite. The ambulance staff gave care home staff advice and guidance to contact her doctors for a review but she was not admitted to hospital. Care Home 1 contacted the doctors to undertake a review about Miss Y.
25. Between late September and late November 2022 the care home’s records showed Care Home 1 asked for doctor advice about a urinary tract infection (UTI), poor nutritional intake, low blood pressure, a review of her blood pressure medication, oedema on her arms and feet and her deteriorating condition.
26. In mid-October 2022 Miss Y’s doctor advised Miss Y should be admitted to hospital because of concerns of inflammation. Miss X stayed in hospital for two days. She was given antibiotics and returned to Care Home 1.
27. In late November 2022 Mr X said Miss Y was seen by a different doctor at Miss Y’s doctor surgery who said Miss Y needed a blood test and her oedema medications should be stopped until the results of the blood test and altered if needed. The care home’s records showed the doctor stopped Miss Y’s oedema medication on the last day of November 2022. The care provider said it reviewed Miss Y’s care records, but they did not record the need for a blood test. Care Home 1 nurses were interviewed but they could not recall the need for a blood test and there was no record in the clinical diary which would have recorded the request. Care Home 1 said Miss Y’s oedema medication was stopped because her oedema had subsided and her heart rate was low.
28. In early December 2022 Miss Y was well and no daily care notes were made about oedema. In mid-December 2022 Miss Y was admitted to hospital due to oedema, a shortness of breath and chest pain. At the time she was wearing her hearing aid. Miss Y was discharged from hospital into a different care home, in early January 2023.
29. In early February 2023 Mr X made a Stage 1 complaint to the Council and said:
• he paid for a private physiotherapist to help improve Miss Y’s mobility so she could return to her home;
• he was concerned about Miss Y’s swollen foot which he reported to staff and asked for her foot to be elevated but he said nothing was done;
• he said Miss Y was not initially registered with a GP;
• Miss Y needed more intensive physiotherapy following a hospital admission but the doctor blocked the referral and the care home did not support it. He was concerned she may never walk again;
• Miss Y had a hospital admission for malnutrition because she was not eating or drinking;
• a blood test was not taken and Miss Y was taken off medication for 10 days in late November 2022;
• he was concerned about Miss Y’s swollen arm but Care Home 1 did not investigate and then she was admitted to hospital and was discharged to a different care home;
• some of Miss Y’s personal belongings went missing including a hearing aid, medical pendant, watch and clothing; and
• he had withheld payment for Miss Y’s care because of the issues.
30. In late May 2023 the care provider responded to Mr X’s stage 1 complaint. It explained:
• a family doctor registration form was completed in late May 2022 for the local doctors surgery and Miss Y was seen by a doctor from this surgery in mid-June 2022;
• physiotherapists saw Miss Y during her stay at Care Home 1 between late May 2022 and early July 2022 for her mobility but after returning from hospital in late July 2022 she declined the physiotherapy help because she was tired and in pain;
• there was a two-day delay in contacting the doctor before she was admitted to hospital in July 2022 and poor record keeping about a blood test in early September 2022;
• the care home sought health professional advice between late September 2022 and late November 2022 for a UTI, reduced nutritional intake, low blood pressure and her deteriorating condition;
• there was no record of the need to take blood tests in late November 2022;
• Miss Y was well in early December 2022 before she went to hospital in mid-December 2022;
• Miss Y wore a hearing aid after the hearing appointment in early September 2022, staff were not advised of missing clothing items and a call was made to the pendant alarm and watch company in early August 2022 to replace the items but they could only be delivered to a home address and the alarm equipment was not needed in a care home.
31. It apologised for some shortfalls in Miss Y’s care and poor communication and record keeping and said it had taken action including reminding staff about the importance of communication with doctors and other health professionals in a timely manner about changes in condition and keeping accurate records. Care planning coaching had been delivered to relevant staff. It advised Mr X that Miss Y’s outstanding fees should be paid within 14 days.
32. In early June 2023 Mr X remained unhappy and escalated his complaint to stage 2.
33. In late June 2022 the care provider gave Mr X its stage 2 response and explained it could not add further to the stage 1 letter but said if Mr X could provide evidence of the costs of the missing items it would consider refunding the cost. Mr X remained unhappy and contacted us.

Enquiries

34. In response to my enquiries the care provider said:
• it had not heard from Mr X about the costs of Miss Y’s missing belongings;
• there was a new team at Care Home 1 and it had a new process in place for communication with doctors. Records of communication was now sent from the doctors electronically and received by Care Home 1 through email. Telephone calls and follow up emails also took place;
• a new electronic system was now in place for communication with health professionals;
• all relevant staff at Care Home 1 received training on the new electronic care planning;
• a new process was now in place ensuring a belongings list was fully completed on admission and documented when items were removed from the care home and all belongings were now labelled; and
• Miss Y still owed a substantial amount for her care fees.

My findings

Doctors registration

35. The records show Care Home 1 completed a doctors registration form within five days of Miss Y moving into the care home and she was registered with a local surgery and seen by a doctor from the new surgery in mid-June 2022 which was appropriate. The care provider was not at fault.

Mobility

36. Records show Miss Y was seen regularly by a private physiotherapist and an OT between late May and early July 2022. Miss Y was walking with a zimmer frame with help from one staff member in late June 2022 but she also refused to walk on seven occasions in June and early July 2022. After her hospital stay in July 2022 Miss Y refused physiotherapist help and declined to walk due to tiredness and pain. Care Home 1 acted appropriately and encouraged Miss Y to stay mobile through continued OT and physiotherapist visits. It could not force Miss Y to walk and it was not at fault.

Delay in contacting doctor

37. Care Home 1 records show it was aware in early July 2022 about Miss Y’s swollen feet. Miss Y’s daily care record said a doctor should be informed. The physiotherapist also told a nurse she was concerned about Miss Y’s swollen feet. It took two days for Care Home 1 to email the doctor and three days to get medical attention in the hospital. This delay was fault and caused both Miss Y and Mr X frustration and distress.

Health concerns late September to late November 2022

38. Mr X had concerns about Miss Y’s health deteriorating between late September 2022 to late November 2022. The weight charts show she did lose approximately 10 kilograms of weight between late August and late September 2022. The evidence seen shows Care Home 1 sought to support Miss Y at mealtimes, but documented in late September and early October 2022 she frequently refused to eat food offered or ate very small amounts and drank below 1000 millilitres of water a day in this period. A care home cannot force a resident to eat or drink if they do not wish to do so. This was not fault.
39. Care Home 1 sought to support Mrs Y’s food and fluid intake and called an ambulance in late September 2022 and raised this with the doctor on the ambulance staff advice. Care Home 1 continued to raise issues with the doctor between October 2022 and late November 2022 and there is no fault in the way Care Home 1 provided support to Miss Y in this period.

Blood Test

40. The care provider was at fault for poor record keeping in early September 2022 when a blood test team took a blood sample from Miss Y but Care Home 1 did not record this and it did not chase this further. This caused Mr X and Miss Y uncertainty and was not in line with Regulation 17 of the CQC fundamental standards. The care provider has reminded staff about the importance of accurate record keeping and keeping records of conversations with health professionals, which is appropriate to prevent a recurrence of the fault.
41. In November 2022 Mr X said the doctor advised Miss Y needed a blood test. Care Home 1 did not have any record of Miss Y requiring a blood test. Its records showed the doctor told Care Home 1 to stop her oedema medication which it did. Care Home 1 did what the doctor asked and was not at fault. It is not within our remit to investigate concerns about a doctor.

Missing items

42. Mr X raised concerns about Miss Y’s missing belongings. The records show Miss Y did not have a hearing aid when she entered Care Home 1 but Mr X said he gave Miss Y a hearing aid. Miss Y had a hearing test in early September 2022 and then wore her hearing aid after this, including to the hospital in mid-December 2022. Care Home 1 also contacted the alarm company about replacing an alarm pendant and watch but it could not replace these as she lived in the care home. Losing Miss Y’s belongings was fault. The care provider asked Mr X to provide costs for the missing items and it would consider replacing them. This was appropriate. Mr X has not yet been in contact with the care provider but it is still open to him to do so. The care provider has put in place a new process to list belongings on arrival to the care home and document when items left the care home and to label all belongings.

Fees

43. Not all Miss Y’s care fees have been paid for her time living at Care Home 1. The care provider has provided a detailed breakdown of Miss Y’s outstanding care fees. Miss Y lived at the care home and received care and support. There were some failings in the care provided to Miss Y but I cannot say, even on the balance of probabilities, what the outcome would have been if not for the faults. I have therefore recommended a symbolic payment to acknowledge the distress, frustration and uncertainty these failings caused. If Mr X disagrees with the breakdown of the care fees it is open to him to raise this directly with the care provider.

Service improvements

44. The care provider has already put in place a new electronic communication process with the doctor and other health professionals and relevant staff have received training on the new system which is appropriate. Staff have already been reminded about the need to take accurate records. A new process has already been put in place to log belongings on arrival at Care Home 1 and document when belongings leave the care home, also belongings are now labelled. I am satisfied these actions are appropriate to prevent a recurrence of the faults identified and so no further service improvements are required.

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Agreed action

45. Within one month of the final decision the care provider will:
• apologise to Miss Y and pay her £300 to acknowledge the distress, frustration and uncertainty caused by the delay in contacting the doctor in early July 2022 and poor record keeping in early September 2022.
• pay Mr X £100 to acknowledge the separate distress, frustration and uncertainty the faults caused to him.

We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The care provider should consider this guidance in making the apology.

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Final decision

46. I have completed my investigation finding fault causing injustice. The care provider has agreed to take action to remedy the injustice caused and has already taken action to prevent reoccurrence of the faults.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman