Summary: Ms B complains about the standard of care provided to her mother when she was on end of life care. There is insufficient evidence to make a finding of fault as many issues are one person’s word against another. The care records show the Care Provider was giving an adequate standard of care, and meeting Mrs C’s needs.

The complaint

1. The complainant, who I will call Ms B, says the Care Provider gave poor end of life care to her mother (Mrs C) and family in February 2019. Ms B says it was not a calm, tranquil and caring environment and that there was no feeling of comfort, support or confidence. Ms B specifically complains that:

• Staffing levels were inadequate; the staff seemed rushed and stressed, Ms B witnessed one member of staff with his head in his hands, and when two residents with dementia went into the garden the chef had to bring them back inside.
• The call bell was tied to the top of the bed when Ms B arrived to visit her mother. After that it was left on a bedside table out of Mrs C’s reach.
• Mrs C was left on what appeared to be a child’s potty on the floor, she was shouting for help, but no-one came.
• Mrs C’s partner (who has dementia and also lives at the care home) would wander into Mrs C’s room with another resident; Mrs C found this distressing.
• No-one helped Mrs C with food and fluid intake.
• A member of staff referred to a resident in a derogatory manner, calling him ‘the shite’.
• Ms B could not access the en-suite bathroom as it was full of equipment.
• Ms B wanted to stay with her mother overnight but was told she was not allowed and would need permission.
• The manager told Ms B in a corridor that her mother had died. The manager then was unpleasant to Ms B when her sister (who was next of kin) telephoned unhappy that the Care Provider had not told her directly of her mother’s death.
• When Ms B arrived on the morning her mother died, the Care Provider said it could not inform family until it informed the police.
• Ms B says her mother wanted to return to hospital as did not feel safe at the care home, but the manager said the hospital would not have her back.
• Ms B says the mugs were dirty when staff were offering cups of tea.

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The Ombudsman’s role and powers

2. 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. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (Local Government Act 1974, section 26A(2), as amended or 34C)
5. The main person affected by the matter is Mrs C, who has died. Ms B is not the personal representative of Mrs C’s Estate, it would be appropriate for the personal representative to raise any complaint on Mrs C’s behalf. As Mrs C has died the Ombudsman cannot remedy her personal injustice. I can consider any injustice Ms B may have in her own right because of the actions of the Care Provider.

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How I considered this complaint

6. I considered:
• Information from Ms B, including during a telephone conversation.
• Information from the Care Provider in response to my enquiries.
• The Care Quality Commission’s ‘fundamental standards’.
• Responses from both parties to a draft of this statement.

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What I found

7. Mrs C was in hospital and needed to move to a care home for end of life care. Mrs C’s partner (Mr D) already lived at the Limes Care Home so her daughter (Ms E who is Ms B’s sister) arranged for Mrs C to move there also.
8. The Care Provider would need to assess the proposed resident to confirm it can meet their needs and is happy for them to move in. The Care Provider did this by visiting Mrs C in hospital with Mr D and Ms E present. The Care Provider understood that Mrs C needed end of life care and was satisfied it could meet her needs. The Care Provider has looked after several residents who needed end of life care over the last few years.
9. When the resident moves into the care home the Care Provider should carry out an assessment of needs and produce a care and support plan. The Care Provider carried out appropriate risk assessments, assessment of needs, and produced a care and support plan to show how it would meet Mrs C’s needs, including her preferences such as what food she liked or disliked.
10. The Care Provider keeps daily records for its residents. These records show that Mrs C had settled well and was happy to be reunited with Mr D. Ms E and Mr D visited with Mrs C every day, and Ms E would stay for most of the day. The Care Provider noted that Mrs C did not seem to like it if Mr D was not about.
11. Ms B visited on the sixth day of Mrs C’s stay, as she had been on holiday at the time Mrs C moved there. Ms B did not like what she saw and did not think this was the best place for her mother. When Ms B arrived, she says she could not see a call bell, she went to ask a member of staff, who came in and unwound it from a box on the wall above the bed. The Care Provider disputes this and says the bell was looped around the hospital bed rail at the side as it kept falling onto the floor. The only time it removed the call bell was when the bed was washed and made. I cannot know which version of events is correct, so I cannot make a finding of fault. However, from the care records it is evident that for a lot of time Mrs C would have visitors who would have been able to get help if she needed it. The Care Provider was also making hourly checks on Mrs C. Therefore, even if the call bell was out of Mrs C’s reach at the time of Ms B’s visit, I do not find it caused a significant injustice and any injustice would be Mrs C’s.
12. Ms B says the Care Provider left Mrs C on what resembled a child’s potty on the floor. Mrs C was shouting for help, but no-one came, so Ms B had to go and find someone. The Care Provider denies this and says it does not have any equipment that resembles a child’s potty. Mrs C had a catheter, and her preference was to use a commode rather than the toilet. The Care Provider says once they assisted Mrs C to the commode, they would wait outside to give her privacy and dignity, and she would have a call bell to hand if needed. I cannot know which version of events is correct so I cannot make a finding of fault. It would be unusual for a care provider to have any need for a child’s potty and to have such equipment on site. It would be harder for staff to lower residents to the ground to use a potty on the floor, rather than using a commode or toilet.
13. Ms B says Mr D would wander into Mrs C’s room with another resident, and Mrs C would find this distressing. The Care Provider says Mrs C’s room was in a private wing containing three bedrooms, and the area was accessed by a key fob held by staff. The Care Provider says Mr D would only be able to enter the area if staff or family let him through. The Care Provider’s records show Mr D was important to Mrs C, and she wanted to spend time with him. On the five days prior to Ms B’s visit, Mrs C had spent time with Mr D each day. It might be the combination of having Ms B and Mr D there together distressed Mrs C. The Care Provider’s records show Ms B asked staff to remove Mr D from Mrs C’s room so that she could talk to her mother, Mr D agreed, and staff took him away. Therefore, the Care Provider dealt with the matter properly when Ms B raised it.
14. Ms B says nobody helped Mrs C with food and fluid intake. Care staff would bring in a cup of tea and just leave it there. The Care Provider says Mrs C was self-sufficient to eat and drink by herself. The Care Provider’s records say Mrs C needs assisting with diet/fluid intake, but on another document says she has some difficulty but can manage unaided. The daily care records show Mrs C had a good diet and fluid intake, but do not specify whether staff assisted her. As the evidence indicates Mrs C had a good food and fluid intake, I find the Care Provider’s actions did not cause a significant injustice. Mrs C also had family visiting a lot of the time, who would be able to help her. The Care Quality Commission’s (CQC) fundamental standards says the Care Provider must meet the service users nutritional and hydration needs. The daily care records indicate the Care Provider did this.
15. Ms B says the mugs were dirty. The Care Provider says Ms B did not raise this at the time. The Care Provider says it has held a 5* hygiene rating for the last three years. There is insufficient evidence for me to make a finding of fault.
16. Ms B was shocked to hear a member of staff at the Care Provider refer to Mr D by a derogatory name. The Care Provider says Ms B did not raise this concern at the time, and it does not know whether it is true. If Ms B had raised it the Care Provider would have dealt with the matter directly with the staff member. I do not find the Care Provider was directly calling Mr D a derogatory name, but was using terminology used by Mrs C. It might not have been the most professional comment, and it might have upset Ms B, but I have no evidence to find fault and if I did, I do not consider it severe enough to warrant a finding of fault.
17. Ms B says she was unable to use the en-suite bathroom as it was full of equipment. The Care Provider says Mrs C’s family moved her oxygen tank into the bathroom because it blew out hot air and was noisy. Mrs C chose not to use the toilet. I find no fault by the Care Provider, and no injustice. Mrs C chose not to use the en-suite toilet and moving the oxygen tank allowed more space in her room. There would be other bathrooms available for Ms B to use, so there is not a significant injustice.
18. Ms B says she wanted to stay overnight but was told she would need permission. The Care Provider says the senior carer telephoned the manager when Ms B asked if she could stay. The care home does not have a guest room but Ms B was welcome to stay on a chair in Mrs C’s room with a blanket and pillows. The care records show the Care Provider gave Ms B the option to stay on the chair, but she chose not to. There is no fault by the Care Provider.
19. Ms B says her mother told her she didn’t like it at the care home and wanted to go back to hospital. Ms B says she spoke to a staff member who said the hospital would not have her back. This would be correct advice by the Care Provider; the hospital would not admit someone unless there was a clinical need to be there. There is no fault by the Care Provider.
20. Ms B says there wasn’t enough staff to support residents. The CQC’s fundamental standards says the Care Provider must have sufficient number of suitably qualified, competent, skilled and experienced staff. It does not specify how many staff must be on shift per resident. The Care Provider says there are a minimum of five staff on a morning and evening shift and three staff overnight. The last CQC report was from January 2018 so not the relevant time of Mrs C’s stay, however at that time the Care Provider had sufficient staff on duty. It is more likely than not the Care Provider has retained the same staff ratio so meets the CQC’s requirements. I do not find there is fault, and Mrs C’s care records show she was adequately cared for. Mrs C also had the support of family members for much of her stay.
21. Ms B felt the care was so bad she wanted to move her mother. She arranged to meet the manager the next morning. Ms B stayed at a local hotel and returned in the morning. Ms B says as soon as she walked in the manager came running over to her and told her to “stop” and that she couldn’t go any further. Ms B says the manager told her in a corridor that her mother had died. Ms B says the manager said they had to ring the police first and couldn’t tell family until they had done so. Ms B says it was information overload and was not a nice way to be told. The Care Provider says when somebody dies suddenly, they inform the police to ensure everything is legal and on the record. The police told them not to touch anything in Mrs C’s room until they had visited and investigated. Ms B came that morning before the Care Provider had a chance to tell the registered next of kin, Ms E. The Care Provider says when Ms B arrived, they asked her to come into a side room as they had some sad news, but that Ms B insisted they tell her immediately; therefore, they told her in the corridor. I cannot know which version of events is correct and I cannot make a finding of fault.
22. Ms B says they only had her husband’s telephone with them, so contacted some family members to tell them the news. The word got around the family and Ms E was told before the Care Provider had been able to tell her. Ms E then telephoned the Care Provider and Ms B says the manager came over and ‘had a go at her’ because of this. The Care Provider disputes this, they say they asked Ms B whether they should inform Ms E but that Ms B said she would make the telephone calls. Ms E did not find out the news until three hours after her mother had passed away and was told by a third party so it was very distressing for Ms E. There is insufficient evidence for me to make a finding of fault.
23. Ms B made a complaint to the Care Provider after the death of Mrs C. The complaints procedure says the Care Provider will acknowledge all complaints within three days and will give you the name of the person investigating. The Care provider aims to resolve all complaints within 28 days. The Care Provider acknowledged Ms B’s complaint within 24 hours. It did not specify who would investigate but the e-mail was from the Assistant Manager who invited Ms B to a meeting, so I think although not explicit it is clear it was the Assistant Manager who was investigating. The Care Provider suggested that Ms B and Ms E both be present at the meeting. Ms B said she did not need a meeting with Ms E, but that the Care Provider should go ahead and meet with Ms E and let her know the outcome. The Care Provider met with Ms E and offered to meet with Ms B separately; Ms B did not take up this offer. I find the Care Provider responded adequately to the complaint, and in accordance with its complaint’s procedure.

Was there fault causing injustice?

24. It was undoubtedly distressing for Ms B that her mother was on end of life care. Ms B visited the care home and it did not live up to her expectations, this compounded her distress. However, I have no evidence to support a finding of fault against the Care Provider. The records show it adequately assessed whether it could meet Mrs C’s needs, that it was doing so, and that she was happy there. This is supported by other family members.

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Final decision

25. I have completed my investigation on the basis there is no evidence of fault.

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Investigator's decision on behalf of the Ombudsman