Decision Report 202405538

Summary

C complained to the partnership about the care and treatment of their late spouse (A). A suffered from Progressive Supranuclear Palsy (a rare neurological condition that can cause problems with balance, movement, vision speech and swallowing). A was admitted to a community hospital for care and support of their complex needs. C complained about unreasonable falls prevention, nutrition, personal hygiene and incident management. C was concerned that there was little information in the medical notes to show that A was being reasonably cared for. They noted that A had fallen on several occasions, that A had dirty hair, had not been washed and was not receiving enough to eat and drink.

The partnership advised that A was on continuous intervention during the day and 15 minute observations at night for falls prevention, and that falls risk assessments were carried out as part of routine care, although did not provide evidence of this. They advised that Person Centred Care Plans (PCCP) were recorded in A’s records, risk assessments were completed and updated regularly and all staff were receiving personalised one-to-one training on documentation and PCCP.

We took independent advice from a nurse. We found that there was insufficient evidence of falls risk assessments or malnutrition assessments in the records provided, that there were significant gaps in care rounding records and a 5 day period during which A was not offered a wash. We found this to be unreasonable and upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that the care provided did not meet A’s basic needs or keep them safe. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.