Summary: Mrs C complains the Care Provider failed to properly care for her late mother, Mrs D, which resulted in her having to go into hospital where she died shortly after. There was service failure by the Care Provider which caused Mrs D and Mrs C distress and uncertainty. To remedy the complaint the Care Provider has agreed to apologise, refund money to Mrs D’s estate, and make service improvements.

The complaint

1. Mrs C complains Banstead Manor, owned by Hallmark Care Homes, the “Care Provider”, failed to adequately care for Mrs D which resulted in hospital admission for severe dehydration, faecal impaction, and a suspected urinary tract infection.
2. Mrs C says had the care home acted properly Mrs D’s hospital admission, and death shortly afterwards, could have been avoided. The failures have caused Mrs C distress. She has also had time and trouble in dealing with the complaint.

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The Ombudsman’s role and powers

3. 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. If they have caused a significant injustice or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(3 and 4) as amended)
4. 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)

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How I considered this complaint

5. I read the complaint and the associated documents. I spoke with Mrs C and made enquiries of the Care Provider. This included asking for documents and specific questions about its actions. I considered:-
• the Care Provider’s response;
• Mrs D’s care records;
• The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of Care Providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences. I have used the fundamental standards as a benchmark for considering this complaint.
6. Mrs C and the Care Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

What should have happened

7. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
8. Regulation 10 says care providers must make sure they provide care and treatment in a way that always ensures people's dignity and treats them with respect.
9. Regulation 12 aims to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Care Providers must assess the risks to people's health and safety during any care or treatment and act to mitigate risks.
10. Regulation 14 says care providers must meet service user’s nutritional and hydration needs. The associated guidance says care providers,
11. “must include people's nutrition and hydration needs when they make an initial assessment of their care, treatment and support needs and in the ongoing review of these. The assessment and review should include risks related to people's nutritional and hydration needs. Providers should have a food and drink strategy that addresses the nutritional needs of people using the service.”
12. Regulation 17 says Care Providers should “maintain securely an accurate, complete and contemporaneous record” for 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.”

What happened

13. Mrs D moved into the residential care home in 2020. During Mrs D’s residence the family raised several complaints. These included the lack of communication, Mrs D not receiving personal care, support with activities, maintenance of her room, not having access to medication and on one occasion issues about the lack of fluid over several days. For each complaint the Care Provider responded and provided an action plan. The Care Provider’s action plans resolved most but not all the issues; some of which were recurring.
14. At the time of the issues complained of Mrs D had a Stage 2 pressure sore which the Care Provider had referred to the District Nurses (DN) and the GP monitored. On 25 June 2023 the care home administered laxatives to Mrs D.
15. The Care Provider records on 26 June Mrs D was in intense pain, care staff called both the GP and Urgent Community Response team who said the matter could wait until the following day when the GP was due to visit. Care workers got increasingly concerned because of Mrs D’s worsening symptoms and pain and called an ambulance at 16.50.
16. The ambulance arrived at 21.30 and took Mrs D’s vital signs but did not take her to hospital. A GP provided further telephone advice which included repositioning Mrs D every hour and providing regular fluids. Because of concerns about Mrs D’s pain and bowel movements on the same day the care home started a bowel monitoring chart.
17. On 27 June the GP visited and prescribed an enema. A nurse working in the nursing section of the care home administered the enema as the DN could only attend later that day. Although this was not the Care Provider’s responsibility it took this action because it says Mrs D was in severe pain. When the DN attended at midnight they told the care home to continue with laxatives and to keep Mrs D hydrated.
18. By 11am on 28 June care workers concerned by Mrs D’s chronic pain called the GP. The GP advised the DN would give an enema later in the day, which they did at 14.30. Over the next few hours Mrs D’s condition worsened and the care home called the ambulance service. The care home says the ambulance service did not consider Mrs D needed hospital treatment as she was at end of life care. However, after speaking with family and the care home about “new pain” the ambulance service took Mrs D to hospital.
19. Mrs D entered hospital with severe dehydration and faecal impaction.
20. The Care Provider has accepted there were faults in:-
• the recording and management of Mrs D’s fluid intake;
• the recording and management of Mrs D’s food intake;
• risk assessments generally and particularly of Mrs D’s bowel movements.
21. It agreed to take the following actions:-
• staff should review risk assessments when there are changes to a resident’s condition, so they fully reflect the risk factors and risk level;
• staff should consider what actions/documentation are needed to monitor the risks on an ongoing basis, and to detect any potential issues/concerns;
• implementation of a management overview system of charts, to include bowel, food, fluid and pain monitoring;
• staff to use the risk assessments to inform outside professionals of their concerns;
• to deliver training to staff about constipation and faecal impaction (signs, symptoms, physiology etc) and the Bristol Stool chart to raise awareness of the condition, actions staff should take and when to escalate. This should include linkage to nutrition and hydration;
• staff to re-read the nutrition and hydration policy and complete the policy awareness quiz.
22. From the second stage response it added:-
• spot checks to ensure residents have access to fluids and staff are aware of the over bed table policy;
• meet with the GP and district nurse team about response times to care home concerns;
• monthly audits of charts by a support team member external to the home, to ensure this is embedded and effective;
• training for relevant managers to ensure staff members are acting in line with the care homes policies and guidance.
23. In response to my enquiries on this complaint. The Care Provider agreed to refund £5054 to Mrs D’s estate for the uncertainty caused by its failures. It said these were the fees paid by Mrs D when she was in hospital. Mrs C asked for a refund of travel expenses to a complaint meeting. The Care Provider says it is not willing to pay back these expenses as it chose the location for Mrs C’s convenience. Mrs C says the alternative offered was at a care home which was not convenient or suitable.

Was there fault causing injustice?

24. I do not intend to re-investigate matters where the Care Provider has accepted service failure. For these parts of the complaint my role is to consider whether the actions the Care Provider has agreed to take is suitable to remedy the injustice caused, and improve future services.
25. As Mrs D has died we cannot remedy her personal injustice but we can consider whether there is any unremedied injustice to Mrs C.

Food and Fluid monitoring

26. The Care Provider did not properly record Mrs D’s food or fluid intake. This includes the:-
• points at which to start recording the intake, including when someone is at increased risk such as when they have a urine infection;
• recording of intake both in frequency and detail;
• analysis of recorded food and fluid;
• taking action when the food and fluid intake was low.
27. This is not in line with Regulation 14 and is service failure.
28. The GP provided advice to the care home about regular prompting with fluids and to monitor bowel movements. The records do not evidence the care home took this action consistently. This is service failure and a potential breach of Regulation 12.
29. Mrs D entered hospital dehydrated. I consider on balance given the low levels of fluid Mrs D was recorded as having it is more likely than not had the Care Provider acted sooner Mrs D would not have got dehydrated.
30. I also consider on balance the lack of monitoring and encouraging Mrs D with fluid was a contributory factor in Mrs D’s recurring UTI’s and potentially in her faecal impaction.
31. Because of the service failure Mrs D has the injustice of not having the care she needed; and Mrs C the distress and frustration the Care Provider did not properly meet Mrs D’s care needs.

Bowel Monitoring

32. The Care Provider failed to properly risk assess Mrs D for constipation. This is a potential breach of Regulation 12. The Care Provider says although it did not complete a risk assessment it is unlikely it would have identified Mrs D’s constipation earlier as the GP raised no concerns at the time. The Care Provider says the GP felt Mrs D’s abdomen on 13 June and found it “non-tender”. In response to my draft decision the Care Provider says this was taken from GP consultation notes. There is no record of this in the Care Provider’s records. Notwithstanding this there was a further 13 days when care staff did not monitor Mrs D’s bowels during which time Mrs D developed faecal impaction.
33. Mrs C has the uncertainty the Care Provider could have done more to prevent faecal impaction and Mrs D suffered more than she should have.

General recording

34. The Care Provider uses an electronic system to record interventions however there is a lack of connection between care plans, advice and daily records. In response to my draft decision the Care Provider says this disconnect is because the system is intended for electronic use and not in a printed format. It says the fault lies not in the system itself but because of omissions by staff members. I have no reason to doubt what the Care Provider says about the electronic system. There are however gaps in the recording.
35. The failure to have a complete accurate record of intervention is not in line with Regulation 17 and is service failure. Because of this there is uncertainty about when and what care Mrs D received; and Mrs C has the distress Mrs D did not receive care as she should have.

Skin integrity, wound and pain charts

36. The Care Provider accepts there were flaws in how it recorded Mrs D’s skin and pain. This is not in line with Regulation 12 and is service failure.
37. The Care Provider says any injustice however is limited as Mrs D was already at very high risk and her skin improved. The flaws in the risk assessment and recording therefore did not impact on Mrs D.
38. The Care Provider has however failed to consider how the lack of recording and analysis prevented care workers from considering where and why Mrs D was in pain. The Care Provider related Mrs D’s pain to the pressure area but had they assessed Mrs D’s pain properly it is more likely than not it would have identified Mrs D’s skin was improving. This would have led to further consideration of where the pain was located and may have identified Mrs D’s pain was from another source such as severe constipation rather than her knees or skin integrity. Mrs C has the uncertainty that the Care Provider could have acted sooner which would have avoided or curtailed Mrs D’s pain.

Medication

39. I have considered the Medication Administration Records (MAR). Care staff have accurately recorded prescribed timed medication. There are also care plans which record the trigger points for administering most PRN “to be taken when required” medication. However there is no information about what signs to look out for when Mrs D may need lactulose. I consider this is service failure and a potential breach of Regulation 12.
40. Mrs C has the uncertainty that the Care Provider could have given Mrs D medication which would have prevented the faecal impaction and avoided or curtailed Mrs D’s pain.

General decline of Mrs D’s health

41. The Care Provider accepts it could have done things better however it does not consider its failings were a contributory factor to a decline in Mrs D’s health and her hospital admission. This is because there were several health professionals involved which included district nurses and the GP. While I cannot say on balance Mrs D would not have gone into hospital or her health deteriorated; I consider the collective failures by the Care Provider meant Mrs D’s symptoms were not acted upon as quickly and properly as they should have been. I consider the failure to consider Mrs D and her needs in an holistic person centred way is service failure and potential breach of Regulation 10.
42. There is evidence the Care Provider took steps to record and follow advice from health professionals. The Care Provider also took steps to advocate for Mrs D to enter hospital. However because of the overall general gaps and the lack of detail in recording I cannot say the Care Provider always acted as it should have.
43. Because of these failures Mrs C has the distress and uncertainty that Mrs D’s health may not have deteriorated as quickly as it did.

Financial remedy and travel expenses

44. While I understand Mrs C’s frustration at having to pay for expenses for a trip necessitated by the faults of the Care Provider, I cannot say the Care Provider should refund the costs. This is because there was no pre-arranged agreement the Care Provider would pay these costs. Also it appears the arrangement was a mutual agreement and Mrs C did not raise concerns at the time.
45. The Care Provider has offered a financial remedy which I consider is suitable to remedy the complaint and is above what is in our remedies guidance for distress and uncertainty. Guidance on remedies - Local Government and Social Care Ombudsman

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Agreed action

46. I consider the Care Provider’s actions have caused Mrs C and Mrs D injustice. We cannot remedy Mrs D’s personal injustice as she has died. The agreed actions are therefore to remedy Mrs C’s injustice and to improve future practice.
47. Within one month of the final decision the Care Provider will:-
1. apologise to Mrs C for the uncertainty the service failure has caused her and the distress that Mrs D’s pain and the deterioration in her physical health could have been curtailed or avoided;
2. as agreed by the Care Provider it will pay Mrs D’s estate £5,054 in recognition of the service failure identified.
48. Within three months of the final decision the Care Provider will:-
1. provide an update on the action it agreed to take as part of the complaint response;
2. provide evidence of the review of the food and fluid monitoring and how staff have been reminded of when and how to record charts;
3. provide evidence of how the Care Provider has reminded staff about when and how to record and assess pain;
4. provide evidence of how the Care Provider has reminded staff about when and how to record constipation;
5. provide evidence of how the Care Provider has reminded staff about when to complete risk assessments;
6. remind staff about the need to record interventions, and advice from third parties;
7. review how staff assess when people need PRN medication to ensure it is effective.
49. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

50. I have found the Care Provider’s actions caused Mrs D and Mrs C injustice. I consider the actions above are a suitable remedy. I have ended my investigation and closed the complaint on this basis.
51. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman