Summary: Mr X complained about the respite care his wife, Mrs X received while temporarily residing in a Care Home. Mrs X was admitted to hospital with faecal impaction the day after her return from the Care Home. There was no evidence of fault in the care provided by the Care Home.

The complaint

1. Mr X complained about the care his wife, Mrs X received during her respite stay at Bishop Herbert House Residential Care Home. Mrs X was admitted to hospital with faecal impaction the day after her return from the Care Home, Mr X says the Care Home missed this condition and allowed it to develop.
2. Mr X would like the Council to refund the care home fees, and offer Mrs X compensation for her mental, emotional and physical suffering.

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The Ombudsman’s role and powers

3. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word ‘fault’ to refer to these. We cannot question whether an organisation’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), 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. As part of the investigation I have considered the following:
• The complaint and the documents provided by the complainant.
• Documents provided by the Council and its comments in response to my enquiries.
• The Care Act 2014, The Mental Capacity Act 2015, The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Guidance issued by the Care Quality Commission.
6. Mr X and the Council had opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Relevant legislation

7. 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.
8. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers which meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
9. Safeguarding overview: A council must make enquiries if it has reason to think a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themself. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

The Council’s policies and procedures

10. The Council explained that prior to COVID-19, prospective residents and their family would visit the Care Home before booking a respite stay. The Care Home completed a pre-assessment document in line with the Social Work assessment and conversations with the Social Worker, resident and their family
11. During COVID-19, the Care Home had restrictions in place for the safety of residents and guests. Prospective residents and their family were not able to visit the home in advance of their stay. All communication was via telephone and email. The Care Home completed a pre-assessment document in line with the Social Work assessment and conversations with the Social Worker, resident and their family.
12. The Care Home treats residents according to their care needs and information recorded in their care plans, risk assessments and medication charts.
13. The Care Home monitors residents who they know have bowel problems. It uses food and fluid charts to record intake of food and fluid and keeps an output chart. The Care Home seeks support from the Dietician and Continence Nurse if needed and calls the District Nurse or GP if residents become impacted. Where residents have capacity, Care Home staff only give advice and allow residents to make their own choices.

What happened

14. I have summarised below the key events; this is not intended to be a detailed account.

Background information

15. Mrs X has a long and complex medical history. Mrs X cannot mobilise herself independently and uses a wheelchair. Mrs X has full capacity.
16. Mrs X lives at home with her husband, Mr X, who cares for her with the help of two carers who visit four times a day. Mr X says stool monitoring charts are kept for Mrs X at home.
17. Mrs X’s Care Plan (start date October 2020) for her care at home explains her needs about food and drink, safe transfers, personal care etc. It says Mrs X likes to be supported to use her commode but wears pads for protection. There is no reference to Mrs X suffering with Irritable Bowel Syndrome (IBS), constipation or Faecal Impaction (FI). Neither does it say stool monitoring charts are kept.

Planning Mrs X’s respite care

18. Mr X was due to have a planned medical procedure and could not care for his wife while he recovered. The Council arranged for Mrs X to go into respite care at Bishop Herbert House Residential Care Home, Norwich (Care Home) during this time.
19. Mr X discussed Mrs X needs with the manager of the Care Home over the telephone and by email. There was no face-to-face meeting because of COVID-19 restrictions, as explained above.
20. In a pre-stay summary email, Mr X lists the discretionary medication (the email simply lists these medications, it does not explain what they are used for) and equipment Mrs X will bring with her and explains she will also bring her daily tablet medication box. Mr X provides details of Mrs X’s GP and emergency contact. Mr X also explains Mrs X is likely to still have a Urinary Tract Infection (UTI) on arrival and has been prescribed medication for this by her GP which she will bring with her. There is no reference to Mrs X suffering with IBS, constipation or FI, either currently or historically, within the correspondence.
21. The Care Home completed a pre-assessment based on information it collected from the Social Work Assessment, conversations with the Social Worker and correspondence with Mr and Mrs X. The pre-assessment details Mrs X’s routine, mobility, personal care needs, medication (which she will bring with her), eating and drinking. It explains Mrs X is continent but likes to wear a pad for confidence. It does not refer to any issues with IBS, constipation or FI. There are no special dietary needs, although it records Mrs X’s historical eating disorder. The Care Home did not share the completed pre-assessment plan with Mr and Mrs X.

During Mrs X’s stay in the Care Home

22. Mrs X moved into the Care Home at the beginning of June 2021. When Mr X dropped Mrs X off, he states he told two members of care home staff that Mrs X suffered from IBS and constipation. Unfortunately, the Care Home has no record or recollection of this.
23. The Care Home keeps a daily record of care and support its staff provide. The records show Mrs X often called for help, for example asking for a cardigan or blanket because she was cold, help turning the TV and lights on and off, asking for drinks and snacks. The information sheets also show Mrs X asking to use the toilet and staff supporting her to do so. On a few occasions the records show Mrs X requesting pain killers and Gaviscon.
24. The information sheets show Mrs X went out with her brother during the first week of her stay and returned ‘in a good mood’. She went out again with him in the last week of her stay, just two days before going home.
25. Apart from her usual health conditions and the UTI Mrs X had been prescribed medication for by her GP in advance of her arrival, there were no issues regarding her general health until the third week of her stay. Staff noticed a decline in Mrs X mood, mobility and strength. The Care Home started recording Mrs X’s fluid intake on a hydration chart and completed a urine dip test which showed Mrs X had an infection. Mrs X was prescribed antibiotics and took the first dose within four hours.

Mrs X returned home

26. Mrs X returned home on the morning of 25 June. Mr X says Mrs X looked poorly on her arrival home and could not communicate.
27. On 26 June, Mrs X was in severe lower abdomen pain and was incoherent. Mr X called an ambulance. The hospital staff admitted Mrs X.
28. The hospital discharged Mrs X on 2 July. The discharge letter says Mrs X ‘reported abdominal pain on admission. She reported not having opened her bowels for a few days.’ An Abdominal X-Ray showed faecal loading. It states her main condition was constipation. Mrs X was given a suppository and regular laxatives. Mrs X ‘remained well throughout admission and was discharged home after bowels opened.’ The discharge letter says ‘there is no change to Mrs X’s mental health presentation.’
29. On her return home, Mr X says Mrs X was physically weak and unable to transfer using her standing aid, nor sit in her wheelchair without tilting to the side. He also says Mrs X was suffering from depression and was suicidal.

The complaint

30. Mr X complained to the Council in September 2021. He summarised his complaint into three main points:
• Following her three week stay at the Care Home, Mrs X was hospitalised within 24 hours and spent a week in hospital recovering.
• The Care Home was oblivious to the FI that developed whilst Mrs X was in their care.
• The episode has had a catastrophic effect of Mrs X’s physical, mental and emotional health.
31. The Council completed its safeguarding enquiries in October 2021. The Lead Assessor spoke to Mr and Mrs X, Mrs X’s sister, Mrs X’s GP, staff at the Care Home and staff from Councils adult social services and billing team. The Lead Assessor considered Mrs X’s care and support plans, daily information notes, emails and letters, fluid charts, dip tests, medication charts and information provided by Mr X.
32. The summary of the allegation sets out two main aspects of the complaint. The first is the Care Home did not offer Mrs X showers, and second is the Care Home not carrying out UTI dip test sooner during Mrs X’s stay. A further complaint was also introduced in relation to Mrs X’s lack of bowel movements and the failure to keep a stool record, this is the substance of Mr X’s complaint to the Ombudsman.
33. In concluding the investigation of the third element of the complaint, the safeguarding enquiries said there is ‘…insufficient evidence to link Mrs X’s FI with her stay at the Care Home as a causal factor.’ It also concluded no information was passed to the Care Home about Mrs X’s current or historical bowel problems at the time of admission. It says ‘If monitoring bowels was needed, then the historical bowel-problem should have been mentioned by the family at the time of assessment and admission. Despite detailed “pre-admission” emails from the family, the need for stool-monitoring or any reference to historical bowel problems were not mentioned.’ It goes on to say, ‘Indeed if they had done so without justifying the need to do so, this may have been unnecessarily intrusive.’
34. The Care Quality Commission (CQC) also investigated the matter. It concluded in September 2021 and discussed ‘lessons learned’ with the Care Home and advised it to update its respite booking process. In future, the care plan, medication, GP encounter form and prescription must be checked and signed by the resident or their relative before admission to agree its contents. The Care Home says it has made these improvements.
35. The Council responded to Mr X’s complaint in January 2022. It said ‘Whilst we accept the faecal impaction is likely to have gained severity whilst your wife was at Bishop Herbert House, your wife has capacity to inform staff of her constipation'. The Council echoed the findings of its safeguarding enquiry and concluded there were no safeguarding concerns identified.

Analysis

36. The Care Home were not aware of Mrs X’s bowel problems. Mrs X’s Social Worker provided a Social Work Assessment before Mrs X’s respite stay. It did not state Mrs X has bowel problems. Mrs X’s Care Plan for her care in the home does not record Mrs X’s bowel problems.
37. Mr X did not tell the Care Home of Mrs X’s bowel problems in the preadmission correspondence. Mr X says he told the staff on arrival at the Care Home that Mrs X suffered from constipation. The staff at the Care Home do not recall Mr X saying this. Whilst I do not dismiss what Mr X says, there is no way to verify it and no evidence on which to make a finding of fault against the Care Home.
38. The Care Home cannot anticipate the need of each resident. That is why the care plan and preadmission assessments are so important.
39. Mr X did not tell the Care Home of Mrs X’s bowel problems in the preadmission correspondence. This information was not contained in Mrs X’s social care assessments and was not known to her Social Worker. Therefore, Mrs X’s care plan for her stay at the Care Home also did not include this information.
40. I appreciate Mr X states he told care home staff about Mrs X’s constipation on arrival. Unfortunately, there is no record of this, and the Care Home do not recall him providing this information. There is no way for me to determine what was said in conversation when Mrs X arrived at the Care Home. I can only go from the contemporaneous records available.
41. Mr X had the chance to provide the Care Home with information about Mrs X’s bowel problems by telephone and email before her stay commenced. Unfortunately, he did not do so.
42. I haven’t seen any evidence that Mr and Mrs X told the Council about these issues as part of Mrs X’s social care assessments with the Council. If they had, the Council would have shared this information with the Care Home.
43. Mr X says information regarding Mrs X’s IBS and constipation was provided to the Care Home. He refers to medication provided specifically for these conditions which he listed in his preadmission email. No information regarding what the medication is for was provided. Care Home staff are not medically qualified. They administer medication, but it is not their responsibility to draw conclusions about an individual’s medication condition from reading a list of medication.
44. Mr and Mrs X did not ask the Care Home to complete stool monitoring charts and explain why these were necessary. The Care Home advised that monitoring bowels is not a standard requirement and to do so without justifying the need would be unnecessarily intrusive. These were therefore not in place for Mrs X.
45. The Care Home’s records show Mrs X regularly called for support to use the commode. She did not express any difficulty in passing stools, nor did she ask for medication or medical attention for this. Had she have done, according to the Care Home’s procedure, staff would have contacted the Dietician, Continence Nurse, District Nurse or GP to provide medical advice and assistance. Mrs X has capacity, she was able to tell staff she was constipated and seek medical attention.
46. Mr X has correctly said Mrs X is not responsible for her own diagnosis. She does however have capacity and was able to communicate to staff that she was feeling unwell. Had Mrs X told staff she felt unwell, they could have contacted the GP and got her medical attention.
47. The Care Home did notice a decline in Mrs X’s health towards the end of her stay. I found staff were proactive in dealing with Mrs X on noticing a change in her health. They put in place a hydration chart for Mrs X and completed a urine dip test (three days before she left the Care Home). Mrs X received antibiotics which she took the first dose of within four hours. Mrs X was well enough to go out with her brother the following day, two days before she left the Care Home
48. The Care Home did not contact Mrs X’s emergency contact (Mrs X’s sister) when noticing a decline in her health, although her brother did visit during this period. The Safeguarding review highlighted Mrs X’s sister did speak with the Care Home at the time of Mrs X being unwell. She considered the Care Home were ‘very much on top of everything and dealing with things, talking to the GP etc as necessary.’ Despite the Care Home not telephoning Mrs X’s emergency contact, she was still aware of Mrs X’s health. I have not seen any evidence that would suggest the Care Home specifically telephoning the emergency contact would have made a difference to Mrs X’s condition.
49. I found the Care Home administered Mrs X’s medication from Mrs X’s medication box as directed, including prescribed medication for constipation.
50. Mrs X did not bring her discretionary medication for constipation with her to the Care Home. There are no records to suggest Mrs X requested her discretionary medication for constipation or express she did not have it. Mrs X did receive her prescribed medication for constipation. There is no medical evidence to suggest Mrs X’s condition would have been different had the Care Home given the discretionary medication.
51. In summary I found the Care Home were not aware of Mrs X current or historical bowel problems. Mrs X did not tell care home staff she was feeling constipated. The Care Home provided care in line with the Care Plans and information provided. I do not find the Care Home at fault for the care it provided to Mrs X.
52. The Council’s safeguarding enquiry and the CQC investigation recommended improvements to the Care Home’s admission procedures. It is hoped this will prevent a similar issue arising in future. However, this did not affect my findings in this case. The Care Home acted in line with the procedure it had in place at the time, and I do not have evidence to say Mrs X’s bowel condition would have been highlighted using the new procedure.

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Final decision

53. I have completed my investigation. There was no evidence of fault in the care provided by the Care Home.

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Investigator's decision on behalf of the Ombudsman