Summary: There were failings in the late Mrs B’s self-funded care in a nursing home including: poor communication with her family, a failure to provide activities, a delay in obtaining the right medication and in asking the GP to refer her to specialist NHS services, a failure to ensure she received a soft diet and hands-on assistance with eating and a delay in providing a final complaint response. This caused her daughter Mrs A avoidable distress. The Care Provider will apologise and pay Mrs A £1000 to reflect this.

The complaint

1. Mrs A complains about her late mother’s (Mrs B’s) care from September 2018 until her death in January 2019. Mrs B lived in Gracewell of High Wycombe (the Nursing Home). Gracewell Healthcare 3 Ltd (the Care Provider) owned and managed the Nursing Home.
2. Mrs A complains:
1. Mrs B did not receive appropriate nutrition in response to her changing needs
2. Referrals were not made to appropriate health professionals (Speech and Language Therapist, dietician)
3. Communication was poor and care plans were not shared with the family
4. Record keeping was poor (drug charts were not kept properly)
5. There was a lack of appropriate activities in the home
6. There was failure to implement advice from the NHS on discharge from hospital
7. There was a failure to provide appropriate end of life care.
3. Mrs A seeks a full investigation of her complaints and for staff to receive appropriate training.

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The Ombudsman’s role and powers

4. 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. (Local Government Act 1974, sections 34B and 34C)
5. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
6. If we are satisfied with a care provider’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

7. I considered Mrs A’s complaint, the Care Provider’s responses to her complaint and documents described later in this statement. I discussed the complaint with Mrs A. The parties received a draft of this statement and I took comments into account.

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What I found

Relevant law and guidance

8. 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.) The Ombudsman considers the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
9. 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.
10. Regulation 12(i) of the 2014 Regulations 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.
11. Regulation 17 of the 2014 Regulations requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.
12. Regulation 14 of the 2014 Regulations says the nutrition and hydration needs of residents must be met. They must receive suitable nutritious food and fluid to sustain life and good health, with support to eat and drink if needed.
13. Regulation 20 of the 2014 Regulations (the duty of candour) requires care providers to be open and transparent when things have gone wrong. As soon as the care provider becomes aware of a safety incident, it must tell the person or their relative; provide reasonable support, advise them of any further enquiries, keep a written record and apologise.
14. The National Institute of Health and Care Excellence (NICE) guidelines on end of life care are for commissioners, practitioners and providers of health and social care services. The guidelines aim to improve care for people in the last year or so of a chronic condition and recommend:
• Personalised care and support planning including advance care planning
• Systems to identify adults approaching the end of their life and their carers/loved ones
• Holistic needs assessments, offering advance care planning
• A discussion about concerns, wishes, goals and understanding of their illness and preferences regarding care and treatment
• Considering the support carers need
• Support adults to take part in decision about their care, involving people who are important to them
• Care that is co-ordinated between services.
15. NICE guidelines for the care of adults in the last days of life says practitioners should:
• Record care plan discussions with the dying person and those important to them, try and meet their wishes where possible and if not, explain why not.
• Maintain hydration, support the person to drink if possible
• Use the person’s care plan to decide what medicines are clinically appropriate
• Assess what medicines a person is likely to need to control symptoms, ensure they are prescribed as soon as possible
• Before administering anticipatory medicines (medicines to control symptoms of pain and agitation in the last days of life), review the person’s symptoms and adjust the care plan as necessary.
16. NICE guidance Managing Medicines in Care Homes says care providers should have a medicines policy which includes processes which include identifying, reporting and reviewing learning from medicines errors.

What happened

17. The chronology of events in this section is from the Nursing Home’s care records and from the complaint correspondence.
18. Mrs B moved into the Nursing Home in October 2017. She paid for her care privately. Mrs B had dementia.

Care plans and charts

19. The Nursing Home kept care plans which set out Mrs B’s needs and preferences. Dated notes on the care plans indicate the deputy manager reviewed them on 31 December 2018 (and another member of staff reviewed and updated some of them in May and October 2018.)
20. The care plan for activities said Mrs B would like opportunities to enjoy group activities of her choice and described her preferred activities and interests: singing, dancing, walking, animals and gardens, watching TV and musicals.
21. The care plans for nutrition said:
• Mrs B had missing upper teeth and staff needed to observe her for any difficulty with chewing
• She required a juice supplement twice a day
• Staff were to weigh her weekly and report changes to the person in charge
• Staff were to encourage her to choose a well-balanced diet according to her preferences
• She liked snacks mid-morning and at bedtime
• She had a low score for risk of malnutrition and needed a normal diet and routine weight monitoring (minimum monthly)
22. A nurse reviewed and added to the nutrition care plan in May and October 2018:
• Mrs B needed weekly weighing and the GP had prescribed supplements and the chef would provide fortified meals (May).
• She needed to have someone with her when she was eating. She needed encouragement with soft bite sized mouthfuls of food and to sit in the quiet part of dining area. Staff were to offer supplements twice a day in the bottle (May)
• She was a high risk for malnutrition. Staff were to report to the manager if she ate less than half her meal. She needed a fortified diet and supplements. (October)
23. The deputy manager reviewed the care plan for nutrition on 31 December 2018 and added the following:
• Staff were to encourage Mrs B to eat in an upright position, to eat slowly and chew each bite and to ensure her teeth were fitted and her mouth clean and moist
• She ‘pocketed’ food (this is when a person holds food in their cheeks or front of their mouth without swallowing it). Staff should remind her to take small bites and sip fluids during meals and clear her mouth. She needed a carer to sit with her at meals and help her with small amounts at a time. If she refused to eat, staff should try again a few minutes after leaving her
• Her body mass index was less than 20 (this is on the low end of a healthy weight) and she was at risk of weight loss and her weight needed to be monitored weekly
• Staff should report any signs of decreased appetite to the GP
• She had been referred to the dietician
• She was to be weighed every week.
24. A pain relief care plan created on 31 December said Mrs B was unable to request her ‘as needed’ medications and so staff should assess her pain level in line with the abbey scale (a tool to assess pain for patients with dementia and other cognitive problems who cannot articulate pain) and administer medicine as needed.
25. A swallowing care plan created on 7 January 2019 noted Mrs B was at risk of choking and had swallowing difficulties due to her dementia and that staff were to report any difficulties e.g. coughing, gurgling or clearing of throat between mouthfuls.
26. A palliative/end of life care plan created on 14 January said staff were to:
• Adjust personal care according to Mrs B’s abilities
• Communicate with the palliative care team to ensure all her needs were met
• Encourage her to express her feelings
• Ensure her pain was managed (the nurse was to do this)
• Advise the GP and family of any changes in wellbeing
• Provide maximum comfort measures (not specified)
• Encourage the support of family and friends.
27. Mrs B’s care plans noted her family (her two daughters) were to be involved in decisions about her care.

Drug charts

28. Staff recorded all the medicine they gave to Mrs B on medication charts. The charts are all completed correctly.

Dietary instructions to the chef

29. The Nursing Home’s senior staff give written instructions to the chef of each resident’s specific dietary needs and their food preferences. For Mrs B, the instructions around her dietary needs were:
• 3 December 2017: a regular naturally soft diet, fortified.
• 1 October 2018: a fortified regular diet with small portions; smoothies and snacks between meals. Ensure supplements.
• 1 January 2019 – fortified smoothies, must drink ensure 3 times daily. Regular diet, small portions.

Weight charts

30. The Nursing Home weighed Mrs B every week. Her weight was stable at around 52 to 54 kilos until the end of August 2018.
31. Mrs B spent most of September in hospital. Mrs A said her mother ate very little in hospital and her weight dropped to 47 kilos at the end of September when she returned to the Nursing Home. By the middle of November, she weighed 45 kilos and by the end of November, 43 kilos.
32. Mrs B went back into hospital for most of December and was 38 kilos on her return at the start of January 2019. She weighed 35 kilos in the middle of January.

Daily records and relevant correspondence

33. A letter from the SALT to Mrs B’s GP in May 2018 said Mrs B swallowed normally but had a poor appetite, weakness and shortness of breath when she ate. The SALT recommended a normal diet, with softer options little and often.
34. The Nursing Home kept daily progress notes which included a summary of all the activities arranged for the residents. In July 2018, Mrs B took part in exercise to music, maypole dancing, a quiz, bingo, print making and bingo. In August, she took part in chair exercises, a tea dance, tasting crudites, a talk on Japanese gardening, jar decoration, movement to music, bingo, reminiscence, a movie, a quiz, a walk around the village and ballroom dancing.
35. On 3 September Mrs B had a fall. She was treated in hospital for fractures. The discharge summary to her GP indicated Mrs B also had hospital acquired pneumonia and was seen by the SALT team to assess her risk of aspiration (breathing in food) and resumed on a normal diet. A dietician also saw Mrs B when she was in hospital because of concerns about poor food intake. The dietician’s report said Mrs B’s weight was within the healthy range, she had put on weight since 2016 and the dietician advised the GP to stop ensure (a food supplement) and continue with fortified milkshakes and to refer Mrs B to the community dieticians if she lost weight. We note that according to the Nursing Home’s records, Mrs B actually lost weight while in hospital. (see paragraphs 30 and 31).
36. Mrs B returned from hospital on 27 September. Mrs A spoke to a member of staff at the Nursing Home before Mrs B’s return to say Mrs B was very weak, had not eaten for the three weeks she had been in hospital and needed surgery to her shoulder, which the consultant did not think was appropriate for her given her physical condition.
37. On 1 October, one of the Nursing Home’s nurses faxed the GP to ask if Mrs B should have food supplements as she had lost over four kilos in hospital.
38. On 2 October, the nurse noted Mrs B was to see the GP because the hospital dietician had stopped her food supplement although she had lost four kilos in hospital (the hospital dietician’s report to the GP said Mrs B had put on 16 kilos since the previous time she was seen in 2016.)
39. On 3 October, Mrs B saw her GP, as she was not eating well and looked pale. The GP reinstated food supplements and staff noted they started these the same day. On 10 October Mrs B saw her GP again as she had been spitting out her food. The Nursing Home’s notes indicate the GP had not decided on a course of action.
40. The notes indicate there were fewer activities in October in the home apart from visits from Mrs B’s family. In November, Mrs B took part in two activities – a musical sing along and a dance.
41. On 18 November, Mrs A told a nurse the Nursing Home had not made any changes to her mother’s care plan since her return from hospital. Mrs A asked for staff to help her mother with eating and for staff to support her to socialise with her friends downstairs.
42. In the last week of November, Mrs B had a poor fluid and food intake and was hesitant to take her medication. On 27 November, she stayed in bed and screamed when staff tried to reposition her. She saw the GP on 28 November and was prescribed penicillin. However, Mrs B was allergic to penicillin. The Nursing Home’s report of the incident set out what happened and the resulting changes to practice:
• The GP prescribed her penicillin. The pharmacy called the Nursing Home to say Mrs B was allergic to penicillin.
• An agency nurse left a message at the GP surgery to change the prescription but she did not report it to the deputy manager and so the correct antibiotic was not obtained and started until the evening of 30 November.
• The manager changed procedure in the home and instructed nurses to ensure acute (urgent) medication was obtained the same day from a local pharmacy (rather than from the home’s usual pharmacy which had a time deadline for receiving and dealing with prescriptions needed on the day). Nurses were also instructed to tell the manager immediately if there was any problem getting medication.
43. Mrs A met the manager on 28 November to discuss Mrs B’s care. The manager later emailed Mrs A with a series of actions arising from the meeting.
44. On 30 November, a senior carer emailed Mrs B’s GP surgery saying Mrs B was not eating or drinking and having difficulties with swallowing. She asked the GP to refer Mrs B to the SALT and dietician.
45. On 1 December, Mrs B remained unwell and drowsy, refusing food and taking only her liquid food supplement. She did not have medication as she was drowsy. Staff called an ambulance and contacted her family. Mrs A told me that family had to insist that staff called emergency services.
46. On 3 December, Mrs A advised staff her mother was having treatment in hospital for a chest infection, thrush in her mouth and throat and a urine infection.
47. On 6 December, the manager emailed Mrs A to confirm the actions agreed during the meeting the previous week:
• To refer Mrs B to the dietician and GP for weight loss immediately
• To instruct the chef to fortify Mrs B’s meals and add supplements, to offer her snacks and encourage eating and drinking
• To keep food and fluid charts once Mrs B returned from hospital
• To support her to attend activities
• To offer Mrs B assistance with eating
• To support her to go to the bistro so she could meet her friend
• To update the care plans to reflect the actions agreed
• Review the malnutrition risk assessment and take weekly weights.
48. By the end of December, Mrs B was well enough to go home. She was walking with assistance but needed supervision. She returned to the Nursing Home on 1 January. A nurse noted she had put a message in the staff diary to say staff needed to sit with Mrs B at meal times to supervise her eating and drinking.
49. The hospital discharge summary said Mrs B had a urine infection and e-coli. She was treated with antibiotics and was noted to have been very unwell during her stay. The summary said that clinicians spoke to the family and a further re-admission to hospital for antibiotics would not be in Mrs B’s interests and her doctors had prescribed anticipatory medicines. (This suggests hospital staff may have spoken to the family about end of life care, although the discharge summary did not say this explicitly.)
50. On 3 January Mrs B was walking fine. She was encouraged to eat but only ate a little.
51. On 4 January, she was encouraged to eat. The senior care assistant noted staff needed to persevere and eating took Mrs B a while.
52. On 8 January, Mrs B saw the GP as she was struggling taking her medicine. The following days she was noted to be shaky and spitting her medication out. She was only eating small amounts of food. The GP was going to look into whether Mrs B could receive her medicine covertly.
53. On 9 January, Mrs B took her medication with difficulty. She ate very small portions with encouragement and assistance of staff.
54. On 10 January, Mrs B was spitting out her food. Staff were sitting with her at meal times.
55. On 11 January, Mrs B was unsettled and calling out. She had paracetamol and her pain relief patch was changed.
56. On 12 and 13 January Mrs B was unsettled. She was walking around and shouting for help.
57. The nurse noted on 14 January that she was going to do an end of life care plan that evening.
58. On 14 January, Mrs B saw the GP again as she was still not eating. The advice was for staff to sit with her at meals, to encourage her to have fluids and high energy drinks. Staff asked the GP to refer Mrs B to the speech and language therapist (SALT) and for Mrs B to have subcutaneous fluids. The GP was going to speak to Mrs A and come back to staff about these requests. The GP said he was going to refer Mrs B to the SALT and had spoken to Mrs A about palliative care and pain relief was to be given regularly.
59. Also on14 January, the Nursing Home’s manager emailed the chef and told him to give Mrs B a soft diet with finger food. The manager also asked nurses to check Mrs B’s diet plan and update it.
60. On 14 January, Mrs B had an injection for pain relief; she had been shouting for help all night beforehand. She had another injection the following day (15 January) and was refusing food and snacks, asking for her mother and asking where she was. Mrs B saw the GP the same day and the GP ‘asked why staff were giving her injections and asked staff to give oromorph (oral morphine, a strong painkiller) first.’ Staff noted the GP was prescribing medicine for oral thrush.
61. Another relative spoke to Mrs B and was concerned because Mrs B was grunting and her speech was slurred. Mrs A’s sister called on 16 January with concerns about Mrs B’s speech. The nurse explained Mrs B was sleepy after pain relief. Mrs A told me the family were concerned Mrs B may have had a stroke, but staff disagreed and said it was due to medication.
62. On 17 January, a senior carer completed a referral for the dietician because of weight loss and spitting out food. A note on the same day said the SALT team called about the referral and was going to contact the home with an appointment. Mrs B remained in her room either in bed or sitting in a chair. Staff sat with her and encouraged her to eat and drink and she took a little food and a few sips of drink. Staff noted they checked on her every 20 minutes.
63. On 19 January, night staff noted Mrs B was awake on most checks and had been taking a very small amount of fluid through a syringe as she found it painful to swallow. Staff had been cleaning her mouth on all checks as her mouth was dry.
64. On 19 January, staff noted changes to Mrs B’s breathing which was shallow and stopped and started and gave Mrs B pain relief. Her family was with her.
65. Mrs B died in the early hours of 20 January; she was noted to be comfortable and pain-free. A member of staff stayed with Mrs B that night in line with the family’s wish for her not to be alone after they left. Staff contacted Mrs A to say her mother had died.

Mrs A’s complaint and the Care Provider’s response to the complaint

66. On 13 January, Mrs A emailed the Nursing Home’s manager with concerns about Mrs B’s diet. Mrs A said staff often told her Mrs B was not eating or drinking. Yet Mrs B was being served standard meals and inappropriate snacks like sandwiches with crusts, large slices of melon and orange segments. Mrs A also said:
• When they visited part way through meals, there was no evidence staff helped Mrs B to eat and plates were left in front of her.
• Mrs B could not swallow or clear secretions. A combination of inappropriate food and a lack of support to eat resulted in significant weight loss
• When Mrs B was in hospital her doctors prescribed palliative medicine which kept her comfortable. She was clearly in pain the previous week, but staff had not considered giving her the palliative medicine
• There were two cups of liquid medicine left in Mrs B’s room.
67. The Care Provider has a standard form called a dietary notification which it uses to describe dietary requirements and preferences for each resident. Catering staff use the dietary notification when preparing food for each resident. The manager interviewed staff at the Nursing Home as part of the Care Provider’s complaint investigation. Notes of the interview indicate there were three diet notifications for Mrs B which all said she was on a normal diet rather than a soft diet. A fourth dietary notification, dated 15 January did not appear to have been given to the chef. The manager said the dietary notification should have been updated when Mrs B returned from hospital at the end of December. The hostess told the manager in interview that in future she would check with care staff and check the dietary notification. The manager asked the hostess to meet with the chef every day so she knew of any dietary changes for each resident before serving their meals. The hostess said she had offered Mrs B a regular meal on one occasion, but a carer told her straight away and so she changed it.
68. When interviewed about Mrs B’s pain management, the nurse on duty said Mrs B had been pain free and sleeping and became agitated just before her daughter visited, but she had not been agitated the whole day. She had a patch and was not in pain. The nurse said she had given Mrs B an injection when she felt this was necessary.
69. The Care Provider’s first complaint response said:
• When Mrs B returned from hospital at the end of December 2018, the deputy manager had reviewed her care plan and changed it to ensure care was delivered in line with her needs and choices. She was supported to eat and drink but would only take a small amount
• She was offered a soft diet although this was not an instruction from the hospital
• She should not have been offered a regular meal on 10 January. The member of staff serving the meal was a relief hostess and did not know about changes to Mrs A’s care plan
• The deputy manager told the SALT team that Mrs B had returned from hospital and a second appointment was being arranged.
• Mrs B was on supplements and her diet was being fortified
• She saw the GP on 14 January for a review and the GP spoke to Mrs A
• An injection of oxycodone (for pain relief) was given on 12 January. Mrs B also had a pain relief patch. She had a midazolam injection (for agitation) on 14 January.
• Two liquid medication pots should not have been left in Mrs B’s room. The care assistant recorded Mrs B had been spitting out her medicine and must have left the pots in the room with the intention of returning to try and offer them to Mrs B again. This was not acceptable though and all care assistants were having training
• Catering and clinical staff were receiving training to address the concerns raised (diet planning, medication management) and a clinical lead nurse was due to start to improve communication and the quality of nursing care.
70. Mrs A was not happy with the first response to her complaint and raised further queries. She met with an operations director in February to discuss her concerns. The operations director apologised and said:
• She was concerned about clinical safety and she had asked the regional head of care and nursing to do an audit in the home
• She had identified poor practice and had taken actions to address this including:
1. The quality of food and dining experience was poor. One chef had left and the other had a performance plan. The quality of food and support had improved
2. The building had been changed to make it less clinical
3. Nursing and care were not of the standards expected and clinical leadership was weak. A clinician from another home was overseeing improvements and coaching nurses focusing on end of life care, medication management and individual care planning
4. The activities worker had left and the company was replacing her
5. The company needed to be listening to relatives and would be organizing meetings with relatives.
71. Mrs A complained to us in June 2019. We asked the Care Provider to confirm Mrs A had completed its complaints process. The Care Provider issued a further complaint response in September 2019 by the director of operations, who apologised for the faults she identified in the service to Mrs B. The director of operations said:
• Mrs B saw the SALT in May 2018 and in September when in hospital, at which point she had made good progress with weight and no changes to her diet were recommended. So she was on a normal diet as there were no issues with eating and drinking identified
• The hospital did not recommend any changes to her diet in the discharge summary of 31 December 2018
• There was a SALT referral at the start of December, but the SALT did not do an assessment because Mrs B went into hospital. The SALT team called the home on 17 January asking what Mrs B’s clinical needs were. Mrs B had oral thrush and this would have affected her eating and drinking and caused discomfort. Mrs B had been prescribed an anti-fungal cream to treat the thrush.
• The Nursing Home decided to introduce a soft diet to promote better eating and drinking, but this was not on the advice of the SALT
• Staff completed dietary notifications and one of these included a request to change to a soft diet. Each resident had an up to date diet card which was checked at a daily clinical meeting.
• Mrs B was supported to eat and drink from 3 January but by 10 January, she was still finding it difficult.
• As it had been agreed Mrs B was to have a softer diet, this should have been implemented by all staff until Mrs B had received a full assessment from the SALT.
• The hospital prescribed injectable palliative medicine. This was to be given as and when Mrs B required it. It was not given until 12 January. Meantime, Mrs A was receiving other regular pain relief: paracetamol and a pain-relieving patch which was changed every 72 hours. This was appropriate pain management. The palliative medicine would only be given if needed and there was no evidence in the records of increased agitation or pain except when Mrs A was visiting and this resulted in nurses taking action by giving Mrs B an injection. The GP said the injections should only be given with extreme pain and that Mrs B should have oral morphine first.
• Staff should have shared information with the family about end of life care. Regular reviews would have been more supportive for the family
• Medication should not have been left in Mrs B’s room; this was a breach of company policy. Staff had received additional training. Mrs B should have been re-offered the medication within a safe time.
• Activities did not always take place
• The Nursing Home was using a dementia expert to train and support staff.

Findings

Mrs B did not receive appropriate nutrition in response to her changing needs and referrals were not made to appropriate health professionals (Speech and Language Therapist, dietician)

72. The 2014 Regulations (Regulations 9, 12 and14) require a care provider to liaise with relevant NHS teams to secure appropriate specialist healthcare and to have a care plan which meets nutrition needs with appropriate support to eat and drink.
73. Mrs B’s weight was stable until she fell at the end of August 2018 and needed to go into hospital. She lost weight during her first admission to hospital in September 2018. I am satisfied the Care Provider acted in line with Regulation 12 by informing her GP about the weight loss on her return to the Nursing Home. The GP’s response was to restart the food supplements that the hospital dietician had stopped. The GP was responsible for making the referral to the dietician and did not do so at this stage. The GP’s care is not within our jurisdiction.
74. Mrs B continued to lose weight and by the middle of November, Mrs A was raising concerns. A senior carer emailed the GP surgery on 30 November to ask for a referral to the dietician and SALT. I consider the Care Provider failed to act in line with Regulation 12 as it should have contacted the surgery two weeks earlier following the first meeting with Mrs A.
75. I note Mrs B went into hospital at the start of December. It seems unlikely she would have been seen by the dietician or SALT, before being admitted to hospital for an infection, had the Care Provider contacted the GP on 18 November to refer her. I cannot conclude that the Care Provider’s delay caused any injustice.
76. When Mrs B came out of hospital at the beginning of January, there were no specific dietary requirements recommended by the hospital in the discharge summary. However, the Nursing Home’s staff and Mrs A noted Mrs B was having difficulty eating and was pocketing food and so staff were instructed to sit with her and encourage her to eat and drink. It does not appear, based on the chef’s evidence in interview and also based on Mrs A’s observations as a frequent visitor, that Mrs B consistently received a soft diet or that all staff sat with her at each meal and gave appropriate encouragement and assistance with feeding. As Mrs B’s care plan had been updated at the end of December to say she should have a soft diet and hands-on help with eating, this should have happened consistently at all meals. The failure to ensure Mrs B had a soft diet and assistance with eating means her care was not in line with Regulations 9 and 14 of the 2014 Regulations.

Communication with the family was poor and care plans were not shared with the family

77. There is no evidence Mrs B’s care plans were shared with her family or that they were involved in any reviews of her care plans and so I uphold this complaint. The Care Provider’s records do not evidence regular communication with Mrs A about her mother’s care, in particular, about the May 2018 visit from the SALT or about any changes to her care made in light of hospital discharge paperwork.
78. There is no evidence Mrs B or her family were consulted about end of life care. The nurse drew up an end of life care plan without involving Mrs B or her family. This was not in line with NICE guidance on end of life care planning which stresses the importance of involving the person and their close relatives/carers. And the Care Provider also failed to obtain advice and support from the NHS the palliative care team. And there should have been a documented discussion with the family about Mrs B’s preferences for her end of life care. The family should have been offered information about what happens to a person in their final days of life. This may have alleviated some of their concerns about Mrs B’s care and her presentation (such as her slurred speech) in the last few days of life.
79. There was also delay by the Care Provider in providing a final response to the complaint. Its response of September 2019 was prompted by Mrs A’s complaint to us. Taking over six months to complete the internal complaints procedure was a failure in complaint handling.

Record keeping was poor (drug charts were not kept properly)

80. I have looked at the drug charts for Mrs B and they are completed in line with standard recording procedures. I do not uphold the complaint about the drug charts, however there are failings in medication management set out in the following two paragraphs.
81. There was a breach of procedure when Mrs B’s medicine was left in her room. The Care Provider accepted this was fault. It investigated the incident and put in place training for care staff. This was an appropriate response. It acted in line with the duty of candour by explaining what had gone wrong in its complaint response and set out the action it was taking to avoid recurrence (additional training for staff). This was an appropriate response.
82. There was a delay of one to two days in Mrs B receiving antibiotics. The fault was mostly due to the GP’s prescribing error, but when the GP’s error was pointed out by the pharmacist, the Care Provider failed to ensure the correct antibiotic was obtained without delay. It could have done so by contacting the out of hours GP. The agency nurse should have handed over to the appropriate permanent member of staff to follow this up. Mrs B’s care was not in line with Regulation 12 of the 2014 Regulations and she did not receive the medication she needed so care was not in line with Regulation 9. However, the Care Provider completed a written internal investigation into the medication ordering error and this concluded with changes to procedure to minimise the risk of recurrence. That was in line with NICE Guidance on managing medicines in care homes.

There was a lack of appropriate activities in the home

83. There were organised activities available in July and August 2018, which Mrs B enjoyed and were in line with the preferences set out in her activities care plan. Mrs B was in hospital in September and December and so could not take part in activities at the home. There were fewer activities in October and November. Mrs B was not well enough to benefit from organised activities in January 2019.
84. The Care Provider recognised there were not enough activities in its complaint response and apologised.

There was failure to implement advice from the NHS on discharge from hospital

85. The hospital did not give any specific dietary advice when Mrs B left hospital. I do not uphold this complaint.

There was a failure to provide appropriate end of life care.

86. I have dealt with the lack of communication around end of life care in paragraph 77.
87. The Care Provider had a personalised end of life care plan for Mrs B and I am satisfied Mrs B’s care was delivered in line with it. There is no evidence Mrs B was in discomfort in her last days. She received support with eating and drinking in line with her abilities and tolerance; she had frequent checks, frequent assistance with liquid from a syringe and a one to one staff presence in the final hours as her breathing declined, in line with the family’s request. The records indicate she had pain-relief according to the end of life care plan, when she showed signs of pain or discomfort.

Agreed action

88. To remedy the injustice, the Care Provider will:
1. Apologise for the failings in Mrs B’s care and for its poor communication with Mrs A as set out in this statement and make a payment of £1000 to reflect the avoidable distress to Mrs A.
2. Review policies and procedures to ensure residents and their families are involved in care planning and reviewing care plans. In particular, relevant clinical staff should offer residents and their families the opportunity to discuss end of life care and end of life care plans and to receive information about what might happen in the final days of life.
89. The Care Provider should complete recommendation (a) within one month of my final decision and recommendation (b) within three months. I will require evidence it has done so.
90. Mrs A wanted us to recommend the Care Provider to give staff dementia training. I have not made that recommendation because the Care Provider said in its complaint response that it had employed an expert in dementia care to support staff.

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Final decision

91. There were failings in the late Mrs A’s care in a nursing home including
• poor communication with her family
• a failure to provide activities, a delay in obtaining the right medication
• a delay in asking the GP to refer her to the dietician and speech and language therapist and palliative care team
• a failure to ensure she received a soft diet and hands-on assistance with eating in the last few weeks of her life
• a delay in providing a final complaint response.
92. This caused her daughter Mrs B avoidable distress. The Care Provider will apologise and pay Mrs A £1000 to reflect this. It will also review its policies and procedures to ensure residents and their families are consulted about care plans and reviews of care plans.
93. Relevant staff should offer families an opportunity to discuss end of life care and end of life care plans and to receive information about what might happen in the final days of life.
94. I have completed my investigation and shared a copy of this statement with the Care Quality Commission in line with our information sharing agreement.

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Investigator's decision on behalf of the Ombudsman