A nursing home in the Stoke on Trent area

4. Mr I complains about the Home’s care and treatment of Mrs L in March 2019.

Mr I complains the Home:

• failed to meet her dietary needs • failed to remove her hearing aid which caused it damage • left her lying flat with the windows open • caused acute kidney damage • did not have oxygen in the home.

5. Mr I tells us this caused him distress and anger. He also tells us Mrs L’s health deteriorated rapidly due to the negligence of the Home.

6. Mr I wants changes to the Home’s procedures.

Dietary needs

10. Mr I complains the Home failed to provide his mother with appropriate dietary needs while she was a resident in the home. Mr I tells us the Home failed to give his mother thickened drinks and soft foods.

11.The Home explained before admission the hospital gave it a patient profile and trusted assessor document as is normal practice. The Home said after reviewing the documents it was clearly noted how Mrs L was able to tolerate a normal diet and fluids. So when Mrs L was admitted, the food offered was in line with the information the Home had.

12.To decide if the actions of the Home were appropriate and in line with what would be expected, we discussed this complaint with our adviser. They reviewed all the documents provided including Mrs L’s medical records. Our adviser explained there was nothing in the nursing home records to suggest Mrs L should have been on a soft or puree diet when she was first admitted to the Home.

13.Our adviser further explained Mrs L’s pre-discharge documentation, completed by the hospital, stated she needed assistance with feeding but was able to eat a normal diet. Mrs L’s nursing home nutrition care plan from 20 February 2019 also documented that she did not need a soft or puree diet.

14.On admission to the nursing home, it was documented that Mrs L needed assistance with her nutritional needs, which meant she needed physical help from care staff with eating and drinking at all times.

15.On reviewing the food and fluid intake charts from admission to the home on 18 February 2019 until admission to the hospital on 5 March 2019, it is clear to see care staff offered food at all mealtimes and helped so Mrs L could eat. Despite this assistance from care home staff, unfortunately there were times when Mrs L refused meals, spat out her food, kept food in her mouth or would not open her mouth.

16.Mrs L had been at the nursing home for 11 days when nursing staff got advice from the local speech and language therapy (SALT) team. During this period of a week and a half the nursing home staff recognised that Mrs L’s food and fluid intake was decreasing significantly each day. The Home acted in good time by getting appropriate advice from the SALT team. This is in line with the NICE guidance that asks care staff to identify ways to address an individual’s nutrition and hydration needs. We have seen no sign that the SALT team should have been contacted sooner.

17.While we can understand Mr I’s frustration, we have not identified any failings in the actions of the Home regarding Mrs L’s dietary intake.

Hearing aid

18.Mr I complains the Home failed to remove his mother’s hearing aid before bathing her. He tells us this ruined the hearing aid and left Mrs L unable to communicate as she was could not hear anything.

19. The Home apologised this happened and the hearing aid was damaged. It says this has been fed back to staff and all staff will be getting documented supervision to make sure this does not happen again. The Home said it would add this to staff inductions so a similar situation does not happen again. The Home also offered to reimburse the cost of the hearing aid.

20. Our Principles say, ‘where maladministration [fault] or poor service has led to injustice or hardship, public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise’.

21. We recognise the effect not having a hearing aid would have had on Mrs L. But it is clear the Home has acknowledged the failing and made changes to improve its service, as well as apologising and offering reimbursement. We have decided the actions taken are enough to put right the effect of what went wrong.

Left lying flat

22. Mr I complains Mrs L was left lying flat in her bed, despite requesting she be sat upright because she was suffering with a cough.

23. The Home looked into this and explained it monitored Mrs L’s vital signs and each time these were within normal range. It said it contacted a GP about Mrs L’s cough and they confirmed it would review her as part of a scheduled review on 5 March 2019. The Home also explained it could not comment on the positioning of the bed due to the time that has passed. It advised all nurses and carers are aware of the importance of patient positioning and this had been repeated to all staff. The Home apologised it could not give any further information and explained this was because staff could not remember what had happened.

24. While we can appreciate the frustration, we are unable to reach a decision on this matter. We cannot see any concerns documented about a severe cough or breathing difficulties.

Acute kidney damage

25. Mr I complains the Home failed to give appropriate treatment and this led to Mrs L experiencing acute kidney damage. Mr I feels this was because the Home failed to provide thickened drinks, which she needed because she was not swallowing, causing her to choke on normal liquids.

26.The Home repeated how it did not know Mrs L needed thickened fluids. It said it spoke to the SALT team who recommended a different diet type. It explained all of Mrs L’s fluid intake was monitored from when she was first admitted.

27. The Home also explained when there was a noticeable decline in Mrs L’s health and she became less alert, steps were taken to review this and it got advice from the GP. The Home said it told the GP about the decline in fluids but at this time no acute infection was suspected.

28. The Home said from 18 February to 4 March Mrs L was assessed by the GP four times and was reviewed every Tuesday. Mrs L was also reviewed by the fast track nurse.

29. The Home said when it communicated with the SALT team there was no mention that it had assessed Mrs L as needing thickened fluids. As the Home was not aware of this, thickener was never prescribed or requested from the GP.

30. We discussed this with our adviser who explained the acute kidney injury NHS guidance describes acute kidney injury as when someone’s kidneys suddenly stop working properly. It can range from some loss of kidney function to complete kidney failure. Another factor that can cause acute kidney injury is dehydration. The European Society for Clinical Nutrition and Metabolism Guideline on clinical nutrition and hydration in geriatrics recommends that older women should be offered at least 1.6 litres of fluid every day.

31. The records show that on admission to the home Mrs L was already at increased risk of acute kidney injury due to her age and existing chronic kidney disease, and she was unable to maintain her fluid intake by herself. While the nursing home was able to give Mrs L the recommended 1.6 litres on her admission to the home, the food and fluid charts show that each day Mrs L was at the Home, the amount she drank was decreasing. The available records show despite attempts by care staff to encourage Mrs L, she would often decline drinks, and this got worse during her time at the home.

32. Our adviser said a reduction in fluid intake can cause dehydration, leading to an admission to hospital with acute kidney damage. But there was nothing to say the acute kidney damage was as a result of the Home’s actions.

33. We understand Mr I’s distress and frustration seeing his mother deteriorate and we know this was a difficult time for him. After reviewing the information provided and discussing the complaint with our adviser, it is clear to see attempts were made to provide Mrs L with the appropriate levels of fluids to keep her hydrated and reduce the risk of acute kidney damage. We have not identified any signs of a failing with the Home’s actions.

Oxygen

34. Mr I complains the Home did not have any oxygen on the premises and this meant Mrs L had to go to hospital when her health deteriorated. The Home explained a GP will prescribe oxygen, this is sent to a pharmacy and the oxygen then comes from an oxygen company.

35. We looked at whether the Home should have oxygen on its premises in case it is needed.

Our adviser explained nursing homes are not obliged to keep oxygen on the premises in case it is needed. Our adviser said oxygen itself is a prescription drug. It is only prescribed for use by residents in a nursing home once they have had evaluation in hospital by respiratory experts. Our adviser said once a resident has been prescribed oxygen, the prescription will describe the clinical reason for the oxygen, the recommended flow rate and how the oxygen should be used by the person. Mrs L had not been assessed for oxygen and for this reason oxygen equipment had not been brought into the Home for her to use.

36. Our adviser explained there was nothing to suggest Mrs L’s care was affected in any way. Our adviser said if a resident’s health deteriorates to the extent that they need oxygen, they will more than likely need admission to hospital for assessment and treatment.

37. We accept this would have been a distressing time for Mr I. Having reviewed all the information provided and after discussing this with our adviser we have not seen any failings with this part of the complaint.

Care and treatment

38. The Home apologised that Mr I felt it did not give good care and treatment. It said once it became clear Mrs L’s health had deteriorated on 4 March, it took appropriate action by contacting the GP.

39. To decide whether the overall care and treatment was in line with what would be expected, we reviewed Mrs L’s medical records and discussed this with our adviser. The records show on 1 March 2019 the Home recognised that Mrs L’s health was deteriorating. It requested advice from the SALT team and for end-of-life medication from the GP. By 4 March Mrs L had developed a chesty cough and the Home contacted the GP for advice.

40. On 4 March 2019 Mrs I contacted the GP because he was concerned about Mrs L’s chest. He asked a GP to visit his mother at the Home. On 5 March the Home spoke to a GP because Mrs L seemed unwell and was coughing. After a discussion with family, the decision was made to contact the ambulance service so Mrs L could be taken to hospital.

41. Mrs L’s temperature was recorded on 4 and 5 March in the daily nursing notes. At the same time, the Home recorded her pulse, blood pressure and oxygen levels. The records show staff completed thorough care plans on Mrs L’s admission to the Home, which described the tailored nursing care Mrs L needed. The Home also completed assessments for moving and handling needs, the risk of falls, risks of choking, continence and malnutrition.

42. Staff recorded attempts to give oral hygiene, they monitored Mrs L’s welfare throughout the day and the night, washed and dressed her and saw to her continence needs. They would change her position in bed when needed and use lifting equipment to transfer her from her bed to chair and back again. She would be brought into the lounge so she could watch television and staff gave her help at all times so she could eat and drink. They monitored her food and drink intake and when her health deteriorated, they contacted the SALT team, the GP and the ambulance service for advice and assessment.

43. We understand this was a difficult time for Mr I as his mother’s health was deteriorating rapidly. From the records available and after discussing the concerns with our adviser it is clear that Mrs L received proper care and treatment during her stay at the Home. Mrs L’s care needs were assessed thoroughly, and all necessary assistance appears to have been given by nursing home staff. We have not identified any failings in the care and treatment provided.

44. We appreciate it has not been easy for Mr I to bring this complaint and recognise how the events have affected him. We hope we have clearly explained the reasons for our decision.

1. The Parliamentary and Health Service Ombudsman has carefully considered Mr I’s complaint about the care and treatment his mother, Mrs L, had from a nursing home in the Stoke on Trent area (the Home).

2. There are parts of Mr I’s complaint where we have seen no signs that anything went seriously wrong. There are also some parts where the Home has already done enough to put right what happened and how it affected Mrs L.

3. We realise this has been a difficult time for Mr I and his family. We hope we have explained our decision clearly.