Summary: Mr X and Mrs Z complained about the end of life care Mrs Y received in Alexandra House nursing home. They said this caused her to be thirsty, and in unnecessary pain. It also caused her distress, and the family depression and lack of sleep. We found the Care Provider was at fault. The Council has agreed to arrange an apology from the Care Provider and pay the family £400. Also, to provide us with evidence that the Care Provider has made the changes.

The complaint

1. The complainants, whom I shall refer to as Mr X and Mrs Z, complained on behalf of their mother, the late Mrs Y. They said that when Mrs Y was receiving end of life care in Alexandra House nursing home, commissioned by the Council, she:
• was not provided with adequate personalised care or treated with dignity and respect.
• did not receive her pain medication as needed.
2. Mr X and Mrs Z say a safeguarding enquiry found Mrs Y was not given pain medication. She was also left with a “stagnant smelling” drink not fit for drinking and was also told to toilet in her pad which she found distressing.
3. Mr X and Mrs Z say Mrs Y was caused harm and distress and the family suffered depression and lack of sleep. They would like confirmation the Care Provider has learned lessons and put new processes in place as it said it had, so this would not happen to other people. They would also like an apology and a financial payment in recognition of the impact on Mrs Y and her family.

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The Ombudsman’s role and powers

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. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word ‘fault’ to refer to these. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
6. 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)
7. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

8. (Local Government Act 1974, section 26A(2), as amended). We are satisfied that Mr X and Mrs Z are suitable people to complain on Mrs Y’s behalf.

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How I considered this complaint

9. I considered information from the Complainant and from the Council.
10. I sent both parties a copy of my draft decision for comment and took account of the comments I received in response.

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What I found

Background

The Care Quality Commission

11. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.

What happened

12. In early 2020, Mrs Y was discharged from hospital to Alexandra House nursing home run by Runwood Homes Limited (the Care Provider).
13. Mrs Y sadly died towards the end of May. Following contact from Mrs Y’s family, CQC raised a safeguarding concern with the Council. Family said Mrs Y had been left in pain and not received the correct dosage of pain medication at regular intervals. They also said the Care Provider had not treated Mrs Y with dignity as, for example, care workers told her to use her pad when she needed to go to the toilet. They said the Care Provider did not provide her with care that was tailored to her need; it fell below the standard expected. In June, the family wrote to the Council.
14. The Council began its enquiry and gathered detailed information from both Mr X and Mrs Z, and the Care Provider. At the end of August, it updated Mr X on progress with the enquiry and they agreed to close the investigation.
15. In October, the Council continued its investigation, gathering further information from the Care Provider.
16. In November 2020, the Council responded to Mrs Z’s complaint. It apologised that it had not updated her since August and said it continued to work with the Care Provider to achieve an outcome to the safeguarding enquiry. It said it was working with staff to improve standards of communication so it takes place in an “efficient and robust” way.
17. In February 2021, the Council contacted Mr X and Mrs Z to provide a further update and in March, sent them the outcomes of the enquiry.

The safeguarding enquiry

18. I have not included all the issues considered, only those most significant to this investigation. Overall, the safeguarding enquiry found the issues “partially substantiated”. With respect to care workers forcing Mrs Y to use a pad instead of hoisting her to use the toilet, it was inconclusive. This was because care workers sometimes hoisted Mrs Y, and the family said staff had not adequately considered alternatives such as bedpans when she was too unwell to hoist.
19. The enquiry was also inconclusive over the issue of the pain relief. The Council consulted with medical professionals in deciding this. The enquiry made recommendations linked to this because the records should have been clear. The issue of inadequate fluid intake was also inconclusive because the records were inconsistent.
20. The enquiry was inconclusive over the issue of the stagnant drink as there was no evidence to support either Mr X’s or the Care Provider’s views which differed.
21. It found a concern of the Care Provider not referring Mrs Y to the GP for a possible chest infection as not substantiated.
22. The enquiry noted the Care Provider had taken action to address concerns about pain management:
• All staff to undertake end of life training; including pain management.
• All team leaders to undergo retraining in the use of the Abbey pain score and analgesic ladder.
• Staff to review all residents on end of life care at least twice daily and suitable care plans followed.
• The Care Provider had provided support and training to educate staff on end of life and the importance of communicating with family and understanding the emotional impact.
• The Care Provider also accepted that some staff lacked the knowledge and skills to support residents and their family during end of life care. It has set up a training programme to improve staff skills.
23. The enquiry made recommendations for staff to improve record keeping:
• The medication administration record should include the time given, dosage and a clear, identifiable signature.
• To introduce separate food and fluid charts when needed, for example at end of life or during a decline in the person’s health.
• To use clear records of the person’s wishes and a person centred approach to care planning.
• To have clear discussion with family about care interventions and make clear records of this.
• To get a hospital discharge report before people are discharged to the home so there is clarity about any changes in need or medication.
24. The Council said its Quality Improvement team (jointly with the local CCG), carried out an audit across all aspects of care and management. This considered the outcome areas of safe, effective, caring, responsive and well led and made recommendations.
25. Within this, it considered whether the Care Provider was treating residents with compassion, kindness, dignity and respect. They found that residents were treated well and noted only occasional negative responses to one resident with specific difficulties. It recommended:
• The Care Provider reinforce with staff the need for accuracy when signing for medication given and ensure more consistent practice across the units with daily audits.
• That information in individual care plans is accurate and consistent.
• Action to improve communication within the home and allow residents and family members to raise concerns / feedback and the Care Provider to respond to these appropriately.
26. Mr X and Mrs Z declined an invitation to meet with the home management. They wanted an apology from the Care Provider and a donation in remembrance of Mrs Y.
27. I have not further investigated these events because the Council’s safeguarding enquiry was thorough, and I would be unlikely to add anything to this.

Was there fault which caused injustice?

28. Many of the enquiry findings were inconclusive because the Care Provider’s recordings were not satisfactory. This means we do not know what care it provided to Mrs Y and it is likely, on the balance of probabilities, that it was not enough. Without satisfactory records of the care needed and the care to be provided, Mrs Y was put at an increased risk of harm. We cannot now put right any injustice to Mrs Y because she has died, but these faults also caused the family significant and avoidable uncertainty and distress at a difficult time.
29. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), I would usually share the final decision with the CQC. However, on this occasion, CQC has already been involved with the Care Provider following these events so I have not done this.
30. We do not recommend payments to charity or to fund a memorial to remedy injustice to a deceased person. I have, however, recommended payments to Mr X and Mrs Z so they can, if they choose, make a donation.

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Agreed action

31. 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. So, although I found fault with the actions of the Care Provider, I have made recommendations to the Council.
32. To remedy the injustice identified above, I recommended the Council:
• Arrange an apology to Mr X and Mrs Z from the Care Provider. This should detail progress on actions taken to improve in those areas detailed above.
• Pay Mr X and Mrs Z £200 each for the uncertainty and distress it caused.
• Provide evidence of checks on the recommendations made by the safeguarding enquiry and quality monitoring exercise.
• Complete the first two recommendations within one month of my investigation and the third within three months.
33. The Council agreed to complete these actions.

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Final decision

34. I have completed my investigation and uphold Mr X and Mrs Z’s complaints that Mrs Y:
• was not provided with adequate personalised care or treated with dignity and respect.
• did not receive her pain medication as needed.

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Investigator's decision on behalf of the Ombudsman