Summary: There is evidence the care provider failed to record important information about the late Mrs X which might have led to quicker treatment of her fractured hip. Instead, care staff made incorrect assumptions about her symptoms. The care provider also failed to treat Mrs X with respect and dignity. It agrees to apologise to Mrs A, review its admissions processes and offer Mrs A a sum which reflects the distress and uncertainty it caused.

The complaint

1. Mrs A complains about the care and treatment of her late mother Mrs X in the care home. She says Mrs X was left alone in her room, hearing aid batteries were not replaced so she was isolated, her personal hygiene was neglected, she suffered multiple urinary tract infections and did not receive proper and prompt medical attention after a fall.

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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 injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

5. I considered the information provided by the care provider and by Mrs A. Both Mrs A and the care provider had the opportunity to comment on a draft of this statement and I considered their comments before I reach a final decision.

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What I found

Relevant law and guidance

6. 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.
7. Regulation 9 says the care and treatment of service users must-

(a) be appropriate,

(b) meet their needs, and

(c) reflect their preferences.

8. Regulation 10 says service users must be treated with respect.
9. Regulation 12 says care and treatment must be provided in a safe way for service users. That includes ensuring there are arrangements to respond appropriately and in good time to people’s changing needs.
10. The care provider’s falls procedure says that “The following information must be recorded in the care plan or risk assessment:

• any history of falls, no matter how minor;

• any medical risk factors, for example, osteoporosis or blood pressure

problems”

It says, “ Where a risk has been identified, the care plan must reflect what has been done to reduce the risk”.

11. In February 2023 we published guidance for care providers on good record keeping. We said “daily care notes, together with (where appropriate) risk assessments, accident reports, food and fluid and medication charts, are one of the first things we ask a care provider for when we start investigating a complaint. They form vital contemporaneous evidence and enable us to gain insight into howa care provider responded to a resident’s needs, how staff took necessary action where patterns of increased need developed (for example weight loss), and how relatives’ concerns were monitored”. We concluded, “ We are likely to find a care provider at fault where records are illegible or have clearly been changed after the event, where they are inadequate for their purpose, or where they omit essential information or include misleading information.”

What happened

12. Mrs X was admitted to the care home in February 2023 on a rehabilitation basis. She had not been managing her own care well at home and her GP suggested a short stay in the care home to enable her to return to a baseline level to continue living independently. Mrs A, her daughter, says her mother had lived independently, managed her own daily routine and had had a wide range of activities until recently when she had started to stay in bed, forget to take her medication and become dehydrated.
13. The admission records show that Mrs X had a hearing aid but it does not mention battery replacement, although Mrs A says that at the admission assessment she had told staff the hearing aid batteries needed replacing every three days. It says she had reduced mobility, had a history of falls and walked with a Zimmer frame. It does not mention her osteoporosis (Mrs A says Mrs X had had a hip fracture in 2019 and a fractured sternum in 2022). She was noted to be independent with personal hygiene and dressing. The aim of the stay was described as ‘to work alongside the therapy team ready for discharge home’.
14. The care home records show that although Mrs X was offered the choice to eat in the dining room she usually chose to stay in her room. Mrs A says that Mrs X was effectively left in her own room with minimal human interaction and because the care staff did not change her hearing aid batteries, she could not even enjoy her television.
15. Mrs X had a number of urinary tract infections while she was in the care home. Mrs A says as a result she suffered from confusion and her personality changed. The care home records, which at initial assessment said “(Mrs X) has capacity but can become forgetful” now noted on 19 March and 23 March that Mrs X was “confused due to UTI”. Mrs A says her mother was prescribed antibiotics three times in the home, but the problem was not resolved until she was later admitted to hospital.
16. On 20 March Mrs X fell in the home in the night after visiting the bathroom unaided. The care notes say staff called 111 and were told to monitor Mrs X’s condition and call again if the situation changed. An Occupational Therapist visited on 24 March as Mrs X was said to have poor mobility and be leaning to the right.
17. Mrs A says the care provider did not notify the family of the fall, it was only when they next visited and saw falls sensors on the floor that they were told what had happened.
18. The care provider says the records show that staff adhered to the falls injury checklist for the 32 hours following Mrs X’s fall. The care provider says that although the final four entries for the 48 hours post-fall were not completed on this form, they were documented on the usual observation records.
19. The care notes show that although concerns were raised with the Advanced Nurse Practitioner (ANP) by the care team leader on 24 March – that Mrs X had a poor appetite, was not eating or drinking, had poor mobility and was leaning to one side – the advice of the ANP was that Mrs X probably still had antibiotics in her system and she should be reviewed again a few days later. On 27 March the ANP prescribed more antibiotics.
20. A diary note entry for 30 March says, “pain in left hip suspecting broken hip due to fall 10 days ago noticed leg shortening and rotating”. Mrs X was admitted to hospital for emergency hip surgery. Following the hospital admission Mrs X’s family moved her to a different care home.

The complaint

21. In June 2023 Mrs A complained to the care provider. She complained that Mrs X had been left isolated in her room, and that care staff had not changed her hearing aid batteries. She said Mrs X had developed a pressure sore (detected in hospital) and that one day when they visited she had been found lying in her own faeces on her bed. She said she had never had a UTI before but had at least three while in the care home. She said no-one had told them about Mrs X’s fall until they queried the falls sensors at their next visit.
22. The home manager replied in August. She explained that the unit where Mrs X had been resident was staffed by carers, who had access to advice from nursing staff. She said all residents were asked if they wanted to join others for meals in the dining room and she noted occasions when Mrs X had done so but said she usually declined. She said the unit team leader said Mrs X preferred to stay in her own room.
23. The home manager said there was no evidence from the skin integrity records or the body maps that Mrs X had developed a pressure sore in the home. She also documented the advice from the ANP which had been given on the prescription of antibiotics for UTIs. She said the ANP had not requested a urine sample however and the staff could not take a sample without such a request.
24. The manager apologised that staff did not know the hearing aid batteries were to be changed every three days.
25. In respect of Mrs X’s hip fracture, the manager said none of the professional staff who had seen Mrs X between 20 and 30 March raised concerns that there might be a fracture. She said she believed the care staff acted appropriately and could not have been expected to recognise a fracture when other clinical staff had not done so. She apologised that Mrs A had not been notified of the fall as she should have been.
26. The manager apologised that the family had found Mrs X in soiled bedding and clothes on one occasion. She said care staff did regularly assist Mrs X with personal care but unfortunately the team leader on duty on the day in question was unavailable for interview and she could not corroborate what was said.
27. Mrs A remained unhappy and escalated the complaint.
28. A different manager replied. She maintained that Mrs X had been asked regularly if she wanted to join others in the communal room or dining room but usually declined to do so. She apologised that no-one had written into Mrs X’s care plan that the batteries in her hearing aid should be changed every three days. She acknowledged there was no specific skin integrity check completed for 11 days before Mrs X’s hospital admission but said none of the care staff had raised concerns about a potential pressure sore.
29. The manager also said she understood Mrs A’s concerns about the repeated UTIs but suggested she speak to Mrs X’s GP about the treatment provided by the ANP. In respect of the delay between the fall and the hospital admission, she said Mrs X had been seen by a number of different professionals during that time but her symptoms were also consistent with the UTI.
30. Mrs A raised her concerns again. She said she felt that where there was no written evidence about an issue (for example of the pressure sore), the care provider’s response was that it had not happened. She said that it was inconceivable that the staff who had attended Mrs X after her fall had not given all the relevant information (for example in connection with Mrs X’s history of falls and osteoporosis) to the 111 call handler.
31. The care provider responded again. The regional director acknowledged there were several areas where the care staff could have done better, not least in the area of record keeping, and he apologised for the distress caused to Mrs X and her family.
32. Mrs X died in October 2023.
33. Mrs A complained to the Ombudsman.
34. The care provider says that staff acted in accordance with the falls management policy and as Mrs X remained settled during the following night, they did not feel the need to call for further advice from 111. They say, “The symptoms (Mrs X) exhibited were consistent with a UTI, which is why no further actions were taken. The staff at Ashwood Park ICP unit are not clinically trained and therefore rely on the advice and instructions of healthcare professionals. A review of the notes shows no indication of a fracture between March 20th and 30th. During this time, (Mrs X) continued her physiotherapy interventions and was assisted with mobility by the occupational therapist.”
35. The care provider says that “Upon admission, Sanctuary Care staff documented in the care plan that (Mrs X) wore a hearing aid and that the batteries should be checked regularly. However, I was unable to find any documentation from external sources providing guidance on how frequently the batteries should be replaced, and no replacement batteries were provided.” The care provider says it had now improved its processes and includes this check in admission documentation. It says Mrs X never asked for her batteries to be replaced.
36. The care provider says, in response to my draft decision, that Mrs X received treatment from a qualified physiotherapist during the time between 20 and 20 March but no fracture was identified by her. She also says it would have been helpful to see the hospital report about the pressure sore, as she says Mrs X suffered from a form of cancer that can resemble pressure damage. She adds that someone presenting with a UTI (like Mrs X) can have impaired mobility, which can cause unsteadiness increasing the risk of trips and falls.
37. The care provider says however that it agrees our recommendations in the interest of achieving closure for all parties.

Analysis

38. The care provider did not properly and consistently document when Mrs X decided to remain in her room, or how she was encouraged to join other residents. I am therefore unable to rely on its assertion that it did so.
39. The care provider failed to document what Mrs A told it at admission about the need to change Mrs X’s hearing aid batteries every three days. That was fault which caused her injustice. It is disingenuous to say, as it has, that although Mrs X had some confusion she had capacity but did not ask for the batteries to be changed. That does not excuse its failings.
40. The care provider acknowledges that it did not document Mrs X’s skin integrity properly from 19 March until her hospital admission on 230 March but simply says that care staff did not report any issues. However, the hospital staff did record a pressure sore present when Mrs X was admitted which the care provider has now given a possible alternative explanation for.
41. Despite its falls management processes, the care provider did not, as its procedures say it should, document “any medical risk factors, for example, osteoporosis” along with the history of falls. The inclusion of that information would and should have informed the assessment and treatment of Mrs X after her fall on 20 March. Instead staff continued to treat her as though her symptoms were caused by the UTI (although I am unclear why that would have led to poor mobility and leaning to one side) and it was another 10 days before she was properly assessed for a hip fracture. That caused significant injustice to Mrs X which the care provider has not properly recognised, or indeed responded to in its replies to Mrs A’s complaint.

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Agreed action

42. Within one month of my final decision the care provider will apologise formally to Mrs A for the way it failed Mrs X.
43. Within one month of my final decision, the care provider will review the way it documents information at admission and let me have details of how it intends to improve its processes, so it complies with its own procedures and avoids being ignorant of essential information;
44. Mrs X has died and the care provider cannot remedy the injustice caused to her by its failings. However, within one month of my final decision, it will offer Mrs A £1000 in recognition of the distress caused to her.
45. The care provider will also offer Mrs A a further £500 within one month of my final decision in recognition that it has caused further distress by failing properly to respond to her complaints.
46. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

47. I have completed this investigation on the grounds that the actions of the care provider caused injustice which the completion of the recommendations above will remedy.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman