Summary: Mr X complains that Chichester Grange Care Home failed to provide adequate care to his mother, Mrs Y. The care home failed to adequately assess Mrs Y’s needs when she was discharged from hospital and it cannot show how it dealt with Mr X’s concerns about Mrs Y becoming dehydrated. The faults caused distress to Mr X and Ms Z which the Care Provider has agreed to remedy by sending a written apology and making a payment of £300 to each of them.

The complaint

1. Mr X complains that Chichester Grange Care Home failed to provide adequate care to Mrs Y when she was discharged from hospital to mitigate the risk of further falls and its communication with her family was poor. Mr X also complains that the care home failed to recognise Mrs Y had dysphagia which prevented her from drinking and failed to recognise the symptoms of her neurological illness had escalated. Mr X considers that poor care and poor communication contributed to Mrs Y’s death.

Back to top

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. 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.
5. 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.
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
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)

Back to top

How I considered this complaint

8. I have:

• Considered the complaint and the information provided by Mr X;
• Discussed the issues with Mr X;
• Made enquiries of the Care Provider and considered the information provided;
• Invited Mr X and the Care Provider to comment on the draft decision. I considered the comments received before making a final decision.

Back to top

What I found

9. The following is a summary of the key events relevant to my consideration of the complaint. It does not include everything that happened.
10. Mrs Y had dementia and a neurological condition. She was a resident in Chichester Grange care home which is run by the Care Provider.
11. Following a fall, Mrs Y was admitted to hospital for surgery. Prior to Mrs Y’s discharge from hospital, Mr X contacted the care home to ask what mitigation measures would be put in place as Mrs Y had a history of falls at night. The care home advised that it would complete a full assessment of Mrs Y’s needs to determine the required risk measures.
12. A few weeks later Mrs Y was discharged from hospital to the care home. The Care Provider has said a member of staff carried out an assessment of Mrs Y’s need by telephone. There is no record of the assessment. The care home carried out a falls risk assessment but there is no record of the mitigation measures required. The care home did not update Mrs Y’s care plan.
13. Mrs Y was discharged from hospital to the care home. She suffered a fall on the first night of her return. Mr X contacted the care home to report Ms Z, a relative, had visited Mrs Y before her fall and raised that no sensor mats or other mitigation measures were in place when she visited. The care home said it would carry out an investigation and respond to Mr X within seven days. There is no evidence to show the care home took this action.
14. I understand Mrs Y was readmitted to hospital following her fall. The care home did not notify Ms Z that Mrs Y was in hospital until she visited the care home several hours later. Mr X has said this caused significant distress to Mrs Y as she did not know why she was in hospital.
15. Mrs Y returned to the care home. The care home carried out an assessment for bed rails for Mrs Y to prevent her from falling out of bed. I understand the care home installed the rails on the same day.
16. Ms Z raised concerns that Mrs Y was suffering a relapse of her neurological condition. The care home’s records note that staff met with Ms Z to discuss this. The records note the care home had increased Mrs Y’s medication as previously advised by her neurologist. The care home’s records also show the home contacted Mrs Y’s neurologist for an urgent review.
17. The care records show the care home chased the hospital for a neurology review but did not receive a response. The records then note Mrs Y had an appointment with the neurologist.
18. Mr X sent an email to the care home raising concerns that Mrs Y was having difficulty swallowing and the importance of ensuring she stayed hydrated. Two days later, Ms Z took Mrs Y to hospital as she was concerned she was dehydrated. Mrs Y was admitted to hospital. Mrs Y sadly passed away a few days later.

Complaint

19. Mr X and Ms Z made a complaint to the Care Provider that it had failed to put in a care plan for Mrs Y’s discharge from hospital following her surgery. This included not installing bed rails and other mitigation measures to prevent Mrs Y from falling. They also complained that senior staff had refused a meeting with them, the care home had failed to notify them that Mrs Y had been readmitted to hospital and Ms Z had found Mrs Y standing unaided.
20. The Care Provider responded to the complaint. It acknowledged that Mrs Y’s care plan should have been updated following her discharge from hospital. But it considered fall mitigation measures were put in place when she returned to the care home. The Care Provider also apologised for staff failing to notify Ms Z of Mrs Y’s further admission to hospital.
21. Mr X and Ms Z were unhappy with the response so escalated their complaint. In their complaint they also raised concerns that Mrs Y had been admitted to hospital with dehydration. They considered the care home had allowed Mrs Y’s neurological condition to escalate without proper intervention.
22. The Care Provider:

• apologised for the lack of a face to face assessment for Mrs Y on her return from hospital. A staff member said they had carried out a telephone assessment but the assessment was not on the Care Provider’s records.
• explained it would generally consider less restrictive mitigation measures before bed rails and the care home has since implemented a tracker for assistive technology such as sensor mats.
• acknowledged the care home had not dealt with Mr X’s complaint in accordance with the care provider’s complaints procedure. It said it had improved communication with families.
• there was no record of the hospital saying Mrs Y was dehydrated.

23. In response to my enquiries, the Care Provider has said:

• Its usual procedures were to complete an assessment face to face or speak to the hospital to ascertain a resident’s needs when discharged from hospital. Following either a face to face or telephone assessment, the management team would discuss what risk mitigation or changes may be required. It would also update care plans and assessments accordingly.
• It has a weekly GP round for any low level concerns but would also contact GP or 111 if had more immediate concerns.
• Residents’ weights are monitored weekly, two weekly or monthly dependent on their needs. At this review any necessary mitigation measures such as food or fluid charts or encouragement to eat and drink are discussed or other measures.

Analysis

Assessment of Mrs Y’s needs

24. In its response to Mr X and Ms Z’s complaint, the Care Provider said the assessment of Mrs Y’s needs was carried out by telephone but there was no record on file. There is evidence to show a falls risk assessment was carried out on the date Mrs Y was discharged from hospital. But there is no evidence that Mrs Y’s care plan was updated or the mitigation measures explained to staff. I therefore cannot be satisfied, even on balance, that the care home carried out an adequate assessment of Mrs Y’s needs when she was discharged from hospital. There is also no evidence to show any discussions of Mrs Y’s needs by the care home management. So, the care home did not follow the Care Provider’s procedures for assessing Mrs Y’s needs on discharge from hospital. It is also potentially a breach of the Care Quality Commission’s fundamental standard for person centred care.
25. I cannot say, on balance, Mrs Y would not have had further falls if the care home had carried out an adequate assessment of her needs. Mr X and Ms Z consider the care home should have installed bed rails to prevent Mrs Y from falling. I cannot know, on balance, if the care home would have installed bed rails if it had carried out an adequate assessment of Mrs Y’s needs. The Care Provider’s approach is to first consider less restrictive mitigation measures. So, I cannot know even on balance what mitigation measures would have been put in place or if these would have prevented a further fall. But the fault will have caused distress to Mr X and Ms Z.

Relapse of Mrs Y’s neurological condition.

26. I am satisfied, on balance, that the care home followed up the relapse of Mrs Y’s neurological condition with medical professionals. Mrs Y’s care records show the care home sought medical advice and tried to arrange an appointment with Mrs Y’s neurologist.
27. But there is no evidence to show the care home acted on Mr X’s concerns that Mrs Y was struggling to swallow and could become dehydrated. The Care Provider has not been able to provide the records for the period when Mr X raised his concerns and the few days before Mrs Y’s admission to hospital. The care home therefore cannot demonstrate its response to Mr X’s concerns and the risks around Mrs Y struggling to swallow, including the risk of dehydration. This means I cannot know, even on balance, if the care provided to Mrs Y during her last few days at the care home was adequate.
28. I do not know if the care home cannot evidence its care due to a failure of record keeping or retention or poor care. But the failure to keep a record of the care delivered to Mrs Y in the last few days before her hospital admission is fault which will cause distress and uncertainty to Mr X and Ms Z. They cannot know if the care provided to Mrs Y was adequate.

Communication

29. The Care Provider apologised to Mr X and Ms Z for the failure to notify them that Mrs Y had been readmitted to hospital. The failure to notify them delayed Mrs Y’s family being able to accompany her at the hospital which caused significant distress to Mrs Y. As she has sadly passed away, this injustice cannot be remedied. But this fault also caused distress to Mr X and Ms Z.
30. The Care Provider also acknowledged the care home failed to deal with Mr X’s complaint in accordance with its complaints procedure. There is no evidence to how the care home provided a response to Mr X at all. This is fault which caused frustration to Mr X.

Back to top

Agreed action

31. That the Care Provider will:
1. Send a written apology to Mr X and Ms Z for the distress and uncertainty caused to them by the faults identified above. 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 I have recommended in my findings.
2. Make a symbolic payment of £300 each to Mr X and Ms Z to acknowledge the distress and uncertainty caused to them by the faults identified above.
3. By training or other means, remind the care home of the need to follow the Care Provider’s procedures for assessing residents’ needs when discharged from hospital.
4. Review its record keeping practices to ensure appropriate records of the care provided to residents are kept. This should include records of how specific concerns about a residents’ health and welfare are managed.
5. Provide evidence to show the improvements made by the care home for communicating with residents’ families.
32. The Care Provider should take the action at a) and b) within one month and the action at c), d) and e) within two months of my final decision. The Care Provider should provide us with evidence it has complied with the above actions.

Back to top

Final decision

Injustice caused to Mr X and Ms Z.

Investigator’s decision on behalf of the Ombudsman

Back to top

Investigator's decision on behalf of the Ombudsman