Summary: Mrs X complained about the level of care provided to her mother, Ms Y, in the last few days of her life by the care home. She also complained about the clearing of Ms Y’s room and the way her belongings were handled. There were failings in the care home’s records in the last few days of Ms Y’s life and it failed to properly safeguard her belongings after her death. The Council, which commissioned the care, should apologise, pay Mrs X £250 and ensure the care home takes action to prevent recurrence.

The complaint

1. Mrs X complained about the way Two Acres care home, on behalf of the Council cared for her mother, Ms Y, in the last few days of her life. In particular, that it did not offer her mother fluids in the last five days, which she believes may have accelerated her death.
2. Mrs X also complained about the care home’s handling of her belongings after her death. In particular:
• A cleaner removed her mother’s belongings from her room despite Mrs X having told the care home she wanted to clear the room herself.
• The cleaner inappropriately stored her mother’s belongings in black bin bags and did not ensure they were kept secure.
• As a result some items were broken and others were missing, including a wedding ring that Mrs X said was in her mother’s room shortly before she died.
3. Mrs X said the failings, and the care home’s response when she complained, had a devastating impact on her at an already upsetting time. She said she wanted an apology from the cleaner and appropriate compensation for the items lost or damaged.

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The Ombudsman’s role and powers

4. 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’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
5. 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)

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How I considered this complaint

7. I considered:
• the information provided by Mrs X and the Council, including relevant care home records;
• safeguarding records provided by the Council where the care home is situated (Council B);
• relevant law and guidance, as set out below; and
• our guidance on remedies, available on our website.
8. Mrs X and the Council had an opportunity to comment on my draft decision and I considered their comments before making a final decision.

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What I found

Relevant law and guidance

Fundamental Standards of Care

9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall. The standards include:
• Person-centred care (Regulation 9): The service user must have care or treatment that is tailored and meets their needs and preferences. Providers must involve a person acting on the service user’s behalf in the planning of their care and treatment.
• Safe care and treatment (Regulation 12): The provider must have arrangements to take appropriate action if there is a clinical or medical emergency.
• Meeting nutritional and hydration needs (Regulation 14). The provider must ensure the service user has enough to eat and drink to meet their needs and provide the support they need to do so.

COVID-19 and care homes

10. The Government issued guidance for care homes at the start of the pandemic and issued regular updates to that guidance subsequently. Relevant to this case, the guidance said that where someone died with confirmed or suspected COVID-19, relatives could not visit them after death, the room would be closed for up to three days and then cleaned by care home staff. This guidance had been relaxed by summer 2021 when the events of this complaint took place.

What happened

End of life care

11. Ms Y had dementia and was very frail. The care home told Mrs X she was in the last stages of life. Mrs X said when she visited her mother care workers told her they were not giving her mother fluids or medication on medical advice. She says when she visited on 13 and 14 August, she asked care staff to offer Ms Y a drink. They did so and Ms Y was able to swallow. Apart from that she said care staff did not offer fluids. She said Ms Y was turned by care workers every two hours, at which point she was briefly awake, but they did not offer fluids then or at meal times.
12. Care home records show blood results for Ms Y were abnormal in early July 2021. The GP advised that further tests may not be in Ms Y’s best interests, as she was very frail. The record says the “aim is to keep her as comfortable as possible”.
13. The GP visited on 4 and 9 August 2021. The record indicated Ms Y was very frail and receiving end of life care. Also on 9 August, the record stated Ms Y refused food. On 11 August, records note Ms Y’s fluid intake was low and she had been unable to swallow her morning medication. On 12 August 2021, the record said Ms Y was unable to swallow her medication. On 13 August 2021 the record said Ms Y was no longer being given food or drink and “mouth care [was] given on [the] advice of the nurse in charge”. On the same day, the GP visited and prescribed end of life medication, although records indicate this was not, in fact, needed. On 14 August, the record stated Ms Y was unable to swallow her medication, but mouth care was given. On 15 August, Ms Y was offered fluids twice but did not drink anything. The record stated she was very sleepy. She died late that evening.
14. In addition to making enquiries with the Council, which commissioned the care, I also made enquiries of Council B, where the care home is located, which carried out a safeguarding investigation in light of Mrs X’s concerns. I have reviewed the safeguarding records and note that:
• the care home reported in the safeguarding referral that it had contacted Ms Y’s GP, who confirmed they were not concerned about the end of life care given. It said the GP had spoken to Mrs X to explain there were no suspicious circumstances around Ms Y’s death and also explained there was no need to involve the coroner’s office;
• CQC noted the care home records supported Mrs X’s view that fluids were offered routinely on 11 and 12 August, and through the night on 14 and 15 August, but not during the day. It said the “recording [the] rationale for why [fluids were not offered at those times] could be clearer”. It also said the care home did not take proper action to safeguard Ms Y’s belongings after her death; and
• Council B concluded the care home had responded appropriately to the complaint by implementing training for staff and adopting better practices around dealing with the belongings of deceased residents.
15. In response to my enquiries, the care home explained it had taken the following action following the complaint:
• arranged training for staff, led by a facilitator from the Health Trust;
• sourced booklets to give to relatives covering issues around end of life care;
• developed a new leaflet on Understanding Fluids and Hydration at the End of Life; and
• implemented a new process where the clearing of rooms must be authorised by a senior member of staff and now uses cardboard boxes rather than black bags to store belongings.

Ms Y’s belongings

16. Mrs X said she spoke to the care home the morning after Ms Y’s death. She told it she wanted to clear her mother’s room. However, when she arrived later that day to do so, she found the room had already been cleared. She said Ms Y’s belongings were in black bin bags, stored at the back of the care home.
17. In response to the complaint, the care home said a cleaner had cleared the room and packed up Ms Y’s belongings in a suitcase and some black plastic bags. It said the cleaner followed past advice on cleaning rooms after someone had died during the COVID-19 pandemic.
18. In the various responses, there was some confusion about whether the cleaner had spoken to a senior member of staff before they did this and whether that senior member of staff had agreed they should clear the room. The care home said the cleaner was very apologetic and that in future rooms would not be cleared without the agreement of a senior member of staff.
19. Mrs X said that due to the way Ms Y’s belongings were stored, some items were broken, including a vase with flowers, and a garden ornament.
20. Mrs X also said some items were missing, including a manicure set in which she said she had placed a wedding ring on the day Ms Y died. The care home looked for the items and those they located were sent to Mrs X. It was not able to locate a pre-lit Christmas tree, some cream, and a manicure set that Mrs X said contained a wedding ring. It said it had asked all staff, but none could recall seeing the manicure set. In its complaint response it offered Mrs X £50 to compensate her for the Christmas tree and cream.
21. In response to my enquiries, the care home said Mrs X had previously told it she would not bring any jewellery into the home because the previous care home had lost all Ms Y’s jewellery.

Complaints handling

22. Mrs X initially raised concerns about the packing up of her mother’s room by telephone. Following this she sent several emails, which the care home responded to, mostly on the same day. Mrs X also met with a supervisor at the care home, although she said they did not answer her questions.
23. The care home provided a formal response on 27 August 2021. It explained that sometimes, in their last days or hours of life, patients are drowsy and unable to consume anything orally. In such cases, for safety reasons, including the risk of choking, the care home would just offer mouth care.
24. In relation to clearing the room, it said the cleaner followed its usual practice during the pandemic but accepted it should have offered Mrs X the chance to do this and apologised for not doing so. It said staff had now been instructed to wait for specific instructions before cleaning rooms.
25. Mrs X raised further concerns about the lack of fluids, and the clearing of Ms Y’s room. The care home responded on 13 September. It apologised for the delay in doing so, which it said was due to seeking advice. It said it had been in touch with the GP and the coroner and all agreed that Ms Y received appropriate care. It had, however, referred the matter to CQC and the Council’s safeguarding team. It had not been able to locate the missing Christmas tree and would reimburse Mrs X for this if she advised it of the cost. It did not accept responsibility for the wedding ring, as it had no record of that being in the care home.
26. Mrs X responded that she had a video taken shortly before Ms Y’s death, which showed the white manicure set on her shelf. She said she was unhappy with the response and the “poor diluted apology”. She said she would be taking legal advice and complaining to us. She complained to us in late September 2021.

My findings

27. The Council commissioned Ms Y’s care and therefore we hold it responsible for faults by the care home.

End of life care

28. By August 2021, Ms Y was very frail and receiving end of life care. She was having difficulty swallowing, which was affecting her ability to eat, drink and take her medication. Records show the GP saw Ms Y on 13 August and prescribed end of life medication for use, if needed. The care home, using guidance from the GP and its own nursing staff, assessed whether it was safe to offer fluids or whether oral mouthcare only was needed. This was not a single assessment but a series of assessments in the last few days of Ms Y’s life.
29. Although I understand Mrs X disagrees with the care home’s approach, neither the GP nor CQC have raised concerns about the way the care home assessed the situation and made those decisions, nor is there obvious fault based on the records I have seen. However, there was a failure to properly record its reasons for not offering fluids between 13 and 15 August, which was fault. This fault leaves Mrs X with uncertainty about whether those decisions were properly made.
30. The care home has arranged training for staff and information leaflets for relatives in response to this complaint, which is appropriate. It is not clear it has provided guidance to staff specifically about record keeping and I will make a recommendation about that.

Ms Y’s belongings

31. There remains some confusion over why Ms Y’s room was cleared and whether that had been agreed by a senior member of staff. As a consequence, there was confusion in the explanations given to Mrs X about what happened. The care home accepts there were misunderstandings and that Ms Y’s room should not have been cleared without consultation with Mrs X. This was fault, which caused Mrs X distress.
32. The care home accepts some of Ms Y’s belongings were stored in black bin bags. It is also clear that it did not have a record of what was removed from the room for storage and was therefore not able to identify whether items were missing. I find the care home did not properly safeguard Ms Y’s belongings, which was fault.
33. Although I have seen Mrs X’s video of Ms Y’s room on the day she died, which does show a manicure set on a shelf in the bathroom, I cannot say whether this contained a wedding ring, nor that was in the room when it was cleared, and the care home subsequently lost it. Nor can I decide whether items were broken by care home staff or were damaged during transport to Mrs X’s home. However, the lack of proper processes to safeguard Ms Y’s belongings means Mrs X is left with uncertainty over what happened.
34. In response to the complaint, the care home has changed its approach and staff should not now clear rooms without agreement from senior staff. However, it would benefit from a written process that also covers how belongings will be kept safe, for which I will make a recommendation. The care home offered Mrs X £50 for the items it agrees it lost, which was appropriate, but this does not address the uncertainty caused to Mrs X referred to above and I will make a recommend a further remedy for that.

Complaints handling

35. The care home responded promptly to the various concerns Mrs X raised. Its emails and written responses were courteous and respectful, and it offered a meeting to discuss her concerns. Although I appreciate Mrs X was unhappy with the apology, there was no fault with the care home’s complaints handling.

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Agreed actions

36. The Council will, within one month of the date of the final decision:
• apologise to Mrs X for the faults I have identified with the record-keeping, the confusion over clearing Ms Y’s room and the failure to safeguard Ms Y’s belongings; and
• pay her £250 for the distress and uncertainty caused.
37. The Council will, within three months of the date of the final decision, arrange for the care home to:
• remind relevant staff of the need to keep full records of the care provided and to record the reasons for not offering food, drink or medication when providing end of life care; and
• develop a written process for dealing with deceased residents’ belongings that includes, where the room is cleared by care home staff, a record of the items that will be stored and the method of storage, to ensure the belongings are kept safe.
38. It will provide us with evidence the care home has taken the above actions.

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Final decision

39. I have completed my investigation. I have found fault leading to personal injustice. I have recommended action to remedy the injustice and prevent recurrence of the fault.

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Investigator's decision on behalf of the Ombudsman