Summary: We do not uphold Mr A’s complaints about his late sister’s end of life care in a care home.

The complaint

1. Mr A complains about his late sister’s (Ms B’s care) in Sussex House (the Care Home). North East Lincolnshire Council (the Council) arranged and funded Ms B’s care. Mr A says:
1. The Care Home did not seek adequate/timely medical support for Ms B on two occasions when she had chest infections. Her bedroom was also cold.
2. The timing of a discussion about funeral arrangements was not appropriate as Ms B had only just been diagnosed with cancer and had no family to support her when the discussion took place
3. The Care Home did not take appropriate action after staff found Ms B on the floor
4. Two members of staff continued with a visit to Ms B in hospital when Mr A had asked them to leave
5. A carer took a gift from Ms B
6. Another relative was named as a third contact for Ms B.

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What I have investigated

2. I have investigated complaints (a) to (c). My reasons for not investigating complaints (d) to (f) are at the end of this statement.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word ‘fault’ to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. We provide a free service but must use public money carefully. We may decide not to start or continue with an investigation if we believe the injustice is not significant enough to justify our involvement. (Local Government Act 1974, section 24A(6), as amended)
4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
5. If we are satisfied with a council’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

6. I considered Mr A’s complaint, the Council’s response to the complaint and documents described later in this statement. Both parties had the chance to comment on a draft of this statement.

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What I found

7. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) We consider the 2014 Regulations and the Guidance when determining complaints about poor standards of care in care homes. The regulations relevant for this complaint are:
• Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences;
• Regulation 12(i) says a care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents.
8. National Institute for Health and Care Excellence Quality Standard 13: End of Life Care for Adults is relevant for providers in health and social care settings. It says people approaching the end of life should receive assessments in response to their changing needs and preferences, with the chance to discuss, develop and review a personalised care plan for current and future treatment.

Key facts

9. Ms B lived in the Care Home from July 2016. She had mental health problems. Ms B was diagnosed with breast cancer in July 2018 and died in October.
10. Staff at the Care Home drew up care plans to meet Ms B’s identified needs and reviewed these regularly to see if they needed to make any changes. I have summarised relevant parts below.
• Communication: Ms B communicated well; she could sometimes get angry and be sharp. She could make all her needs known.
• End of life care: Ms B had just been diagnosed with cancer which had spread to most of her body. Staff had discussed her end of life wishes with her. Ms B said she did not want strangers involved with her end of life care; she would like the district nurses to look after her. She wanted to remain at the Care Home. She did not want to make a will and wanted staff to speak to a relative about funeral arrangements. The plan set out some more details about the funeral service Ms B wanted.
• Mobility: The Care Home completed a falls risk assessment for Ms B. She was a moderate risk. She walked independently and safely without aids. There was no mention of any previous falls.
11. The Care Home’s daily records said:
• On 8 August Ms B attended the breast clinic and was diagnosed with breast cancer. Staff also liaised with the GP about a possible chest infection
• On 23 September, Ms B was in pain and appeared yellow. Staff rang 999 and paramedics thought she may have a chest infection. She went to hospital and returned home the same day with antibiotics for the chest infection
• On 1 October, Ms B went to the hospital; she was told the cancer had spread
• On 9 October, a carer noted Ms B was asleep on the floor at 1.30 am. Staff assisted her into bed and made her comfortable. She had no injuries. She was checked half hourly from there on and no concerns noted. Ms B was breathless at 6.30 am. She also had a swollen stomach. Staff spoke to the out of hours GP who said to phone 999. The paramedics took Ms B to hospital.
12. Ms B was taken to hospital on 9 October where she died two days later.
13. The Care Home’s manager said in a statement that Ms B liked her window open in the day and this is why staff might have said to get her some blankets.
14. The Clinical Commissioning Group manages social care complaints on behalf of the Council. The CCG’s response to the complaint said:
• The manager of the Care Home called Ms B’s GP on 8 August 2018 after the breast clinic advised she had a rattle in her chest. The GP prescribed antibiotics and these started straight away. The GP did not advise a follow-up appointment was needed.
• The deputy manager spoke with Ms B about creating an end of life care plan. Ms B said she was happy to discuss end of life care. A plan was completed and the deputy manager gave a copy to Mr B’s advocate.
• Ms B was breathless on 23 September. She was taken to hospital and later sent home with further antibiotics; she had pneumonia. There was no follow up appointment recommended and Ms B was seeing the district nurse regularly.
• Mr X was added as a third family contact on his request
• Staff found Ms B on the floor in the early hours of 9 October, asleep. There was no evidence of a fall. As she was breathless, staff decided to check her every half hour. She had deteriorated at 6.30 am and so staff called the GP who advised to call an ambulance which happened.

Was there fault?

15. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. Any fault by the Care Home would be fault by the Council.

Complaint (a): The Care Home did not seek adequate/timely medical support for Ms B on two occasions when she had chest infections. Her bedroom was also cold.

16. I am satisfied Ms B’s care in August and September was appropriate and that staff acted in line with Regulation 12 of the 2014 regulations by seeking timely support from the GP and hospital when Ms B showed signs of a chest infection. There was no fault.
17. Staff acted in line with Ms B’s preferences by keeping her bedroom window open. This was in line with Regulation 9 of the 2014 Regulations and there was no fault.

Complaint (b): The timing of a discussion about funeral arrangements was not appropriate as Ms B had only just been diagnosed with cancer and had no family to support her when the discussion took place

18. National guidance on end of life care required the Care Home to discuss Ms B’s end of life care wishes and preferences with her and to devise a personalised care plan. I am satisfied Ms B’s end of life plan was in line with national guidance. Staff involved Ms B’s advocate. There was no fault in not involving Ms B’s family in the discussion as the evidence indicated Ms B was happy to speak about the issue alone.

Complaint (c): The Care Home did not take appropriate action after staff found Ms B on the floor

19. Ms B had no reported history of falls and walked independently. So there was nothing to suggest any particular measures were needed to ensure her safety in bed. Contemporaneous records indicated staff found Ms B on the floor, uninjured. There is not enough evidence to suggest she fell. In any event, I consider staff acted appropriately by checking Ms B for injuries and supporting her back into bed. There was no fault.

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Final decision

20. I do not uphold Mr A’s complaints about his late sister’s end of life care in a care home.
21. I have completed my investigation.

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Parts of the complaint that I did not investigate

22. I did not investigate complaints (d) to (f) because the injustice is not significant.

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Investigator's decision on behalf of the Ombudsman